Healthcare Provider Details

I. General information

NPI: 1467283051
Provider Name (Legal Business Name): ANTON FEDOROVICH SHANIN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 LAUREL CANYON BLVD
NORTH HOLLYWOOD CA
91607-3717
US

IV. Provider business mailing address

12302 DOWNEY AVE
DOWNEY CA
90242-3514
US

V. Phone/Fax

Practice location:
  • Phone: 818-506-4455
  • Fax:
Mailing address:
  • Phone: 310-924-0286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031622
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number95031622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: