Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | MT202598 | PA |
Y | 2084N0400X | Neurologist | MD457769 | PA |
NPI | 1700149895 |
---|---|
Provider Name | Shaista Alam |
First Address | Philadelphia, PA 19107-5211 |
Second Address | Philadelphia, PA 19107-5211 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2012 |
Last Update Date | 27/10/2017 |