Provider Demographics
NPI:1134894181
Name:SHABANOVA, IRINA (MBCHB)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:SHABANOVA
Suffix:
Gender:F
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BURTON AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485
Mailing Address - Country:US
Mailing Address - Phone:843-991-6981
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:718-270-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program