MEDICARE: SHANTALA MASK P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	2911	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2911	OTHER	AZ	PHYSICIAN ASSISTANT LICENSE

General Provider Information

NPI Number	:	1336304427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTALA MASK P.A.

Provider Business Mailing Address
First Line	:	4136 N 75TH AVE
Second Line	:	STE. 101
City	:	PHOENIX
State	:	AZ
Zip	:	85033-3171
Country	:	US
Telephone Number	:	623-849-2220
Fax Number	:	623-849-2574

Provider Business Practice Location Address
First Line	:	4136 N 75TH AVE
Second Line	:	STE. 101
City	:	PHOENIX
State	:	AZ
Zip	:	85033-3171
Country	:	US
Telephone Number	:	623-849-2220
Fax Number	:	623-849-2574

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2008
Last Update Date	:	02/04/2014

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Directions to “ SHANTALA MASK P.A.” Practice Location

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