Provider Demographics
NPI:1245486901
Name:KIELBASA, SHASTA A (MD)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:A
Last Name:KIELBASA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:A
Other - Last Name:KIELBASA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2052
Mailing Address - Country:US
Mailing Address - Phone:413-582-2792
Mailing Address - Fax:413-582-4675
Practice Address - Street 1:30 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2052
Practice Address - Country:US
Practice Address - Phone:413-582-2792
Practice Address - Fax:413-582-4675
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250422207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics