Provider Demographics
NPI:1952497091
Name:SHOSTAK, LAKIN H (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LAKIN
Middle Name:H
Last Name:SHOSTAK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 FIGLAR AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824
Mailing Address - Country:US
Mailing Address - Phone:203-255-5875
Mailing Address - Fax:
Practice Address - Street 1:1305 POST RD
Practice Address - Street 2:#103
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-319-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant