Provider Demographics
NPI:1881778694
Name:JUSTA, SHELLEY
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:JUSTA
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 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:1783 ROUTE 9
Practice Address - Street 2:SUITE 202
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-2409
Practice Address - Country:US
Practice Address - Phone:518-383-2366
Practice Address - Fax:518-383-6022
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01436135Medicaid
NYBB8718Medicare PIN
NY01436135Medicaid