=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902146723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASHEK HEALTH SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2013
-----------------------------------------------------
Last Update Date | 02/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4521 GRACELANN
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-2366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-461-7839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4521 GRACELANN
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-2366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-461-7839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | LARA D MASKEK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 479-461-7839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25902
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------