Basic Information
| Provider Information | |||||||||
| NPI: | 1992477897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARSHAW | ||||||||
| FirstName: | SHAVON | ||||||||
| MiddleName: | |||||||||
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| Credential: | CST, CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 929 W HIGGINS RD | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601953203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472854200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 929 W HIGGINS RD | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601953203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472854200 | ||||||||
| FaxNumber: | 8478850130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2021 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 205780 | IL | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 238.000744 | 01 | IL | STATE OF IL SURGICAL ASSISTANT LICENSE | OTHER |