Healthcare Provider Details

I. General information

NPI: 1609227255
Provider Name (Legal Business Name): MENA SHEHATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 23RD ST STE G10
ASHLAND KY
41101-2886
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-5864
  • Fax: 606-408-6499
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number56895
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number56895
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: