1477983849 NPI number — SHELLY ANN MINISH PA-C

Table of content: SHELLY ANN MINISH PA-C (NPI 1477983849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477983849 NPI number — SHELLY ANN MINISH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINISH
Provider First Name:
SHELLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477983849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 BROADWAY BLVD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102-2372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-242-3991
Provider Business Mailing Address Fax Number:
505-998-1660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 BROADWAY BLVD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-2372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-242-3991
Provider Business Practice Location Address Fax Number:
505-998-1660
Provider Enumeration Date:
11/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA2016-0106 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA2016-0106 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA2016-0106 . This is a "NM MEDICAL LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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