Provider Demographics
NPI:1730549080
Name:SUNESARA, SHABANA (APRN-FNP)
Entity type:Individual
Prefix:
First Name:SHABANA
Middle Name:
Last Name:SUNESARA
Suffix:
Gender:F
Credentials:APRN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 CUSTOMER CARE WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5167
Mailing Address - Country:US
Mailing Address - Phone:209-384-6488
Mailing Address - Fax:
Practice Address - Street 1:2760 3RD ST
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307
Practice Address - Country:US
Practice Address - Phone:209-556-5011
Practice Address - Fax:209-556-5095
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130246363LF0000X
CANP95007976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMS4739922OtherDEA