Provider Demographics
NPI:1033789060
Name:BATTAN-WRAITH, SHAMELE MAHEN
Entity Type:Individual
Prefix:
First Name:SHAMELE
Middle Name:MAHEN
Last Name:BATTAN-WRAITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5058
Mailing Address - Country:US
Mailing Address - Phone:520-626-7747
Mailing Address - Fax:520-626-7747
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-5058
Practice Address - Country:US
Practice Address - Phone:520-626-7747
Practice Address - Fax:520-626-7747
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR77274208600000X, 390200000X
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty