=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598297574
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CSHANTARA LYNN AUDAP M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2017
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2418 E YORK ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-803-3370
-----------------------------------------------------
Fax | 888-803-3331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3512 15TH ST S
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22204-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-619-3699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101273827
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD477326
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------