Healthcare Provider Details

I. General information

NPI: 1063525947
Provider Name (Legal Business Name): SHAISTA PARVEEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 HOSPITAL DR SUITE 204
UKIAH CA
95482-4568
US

IV. Provider business mailing address

260 HOSPITAL DR SUITE 204
UKIAH CA
95482-4568
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-8000
  • Fax: 707-462-1111
Mailing address:
  • Phone: 707-463-8000
  • Fax: 707-462-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA72979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: