Healthcare Provider Details

I. General information

NPI: 1124050794
Provider Name (Legal Business Name): GARY L SHASKY AU.D, F-AAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR BLDG 3 STE153
LA MESA CA
91942-3020
US

IV. Provider business mailing address

12927 SLEEPY WIND ST
MOORPARK CA
93021-2935
US

V. Phone/Fax

Practice location:
  • Phone: 619-589-5414
  • Fax: 619-589-7391
Mailing address:
  • Phone: 310-989-3092
  • Fax: 805-530-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1361
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: