Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 0101266855 | VA |
Y | 207XS0117X | Orthopaedic Spine Surgeon | 0101266855 | VA |
NPI | 1295078848 |
---|---|
Provider Name | Mark Shasti |
First Address | Lansdowne, VA 20176-6821 |
Second Address | Lansdowne, VA 20176-6821 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2013 |
Last Update Date | 27/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7100527830 | (05) | KY |