Basic Information
| Provider Information | |||||||||
| NPI: | 1790726552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMAYUN | ||||||||
| FirstName: | SHAESTA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLAZA | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405353 | ||||||||
| FaxNumber: | 7182405368 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BROOKDALE PLAZA | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405353 | ||||||||
| FaxNumber: | 7182405368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 04/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 137294 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00731535 | 05 | NY | MEDICAID |