Basic Information
| Provider Information | |||||||||
| NPI: | 1962175877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | SHAWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 500 | ||||||||
| Address2: | |||||||||
| City: | ELLICOTTVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147310500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166999032 | ||||||||
| FaxNumber: | 7166999035 | ||||||||
| Practice Location | |||||||||
| Address1: | 961 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
| FaxNumber: | 3154289223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2021 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247ZC0005X | Y | Technologists, Technicians & Other Technical Service Providers | Pathology | Clinical Laboratory Director, Non-physician |
No ID Information.