Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0102X | Surgical Critical Care | A140738 | CA |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | A140738 | CA |
NPI | 1346402039 |
---|---|
Provider Name | Sha'shonda La'trell Revels |
First Address | Los Angeles, CA 90045-5631 |
Second Address | Los Angeles, CA 90095-8358 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2008 |
Last Update Date | 17/01/2020 |