Provider Demographics
NPI:1487142139
Name:BARTON, SHANTA F
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:F
Last Name:BARTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13644
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-0644
Mailing Address - Country:US
Mailing Address - Phone:585-284-1716
Mailing Address - Fax:
Practice Address - Street 1:74 CLAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-4204
Practice Address - Country:US
Practice Address - Phone:585-284-1716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY384267858172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY82-4819001Medicaid