Provider Demographics
NPI:1255057402
Name:WEASE, SHASTA
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:WEASE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 FRONTIER CT APT 1
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-9075
Mailing Address - Country:US
Mailing Address - Phone:502-353-8277
Mailing Address - Fax:270-982-7372
Practice Address - Street 1:907 N MULBERRY ST STE 200
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2018
Practice Address - Country:US
Practice Address - Phone:270-982-7372
Practice Address - Fax:270-982-7372
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist