Basic Information
| Provider Information | |||||||||
| NPI: | 1336150564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAYESTEH | ||||||||
| FirstName: | KAMRAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144108300 | ||||||||
| FaxNumber: | 8144108331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TECH PARK DR STE 1200 | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145346750 | ||||||||
| FaxNumber: | 8145356760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | OS012172 | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1025321390001 | 05 | PA | MEDICAID |