Provider Demographics
NPI:1942378690
Name:DESTASIO, SHAWN CHRISTIE (NP)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:CHRISTIE
Last Name:DESTASIO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:107 WOODLAND RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-7405
Mailing Address - Country:US
Mailing Address - Phone:310-346-6772
Mailing Address - Fax:
Practice Address - Street 1:3701 SKYPARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4753
Practice Address - Country:US
Practice Address - Phone:310-378-8900
Practice Address - Fax:310-791-0789
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA559889363LF0000X
NC5006629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily