Healthcare Provider Details

I. General information

NPI: 1962175877
Provider Name (Legal Business Name): SHAWN DESAI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 CANAL ST
SYRACUSE NY
13210-1203
US

IV. Provider business mailing address

PO BOX 500
ELLICOTTVILLE NY
14731-0500
US

V. Phone/Fax

Practice location:
  • Phone: 315-454-6000
  • Fax: 315-428-9223
Mailing address:
  • Phone: 716-699-9032
  • Fax: 716-699-9035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: