Provider Demographics
NPI:1063497246
Name:NAKAMURA, SHAWN JETT (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:JETT
Last Name:NAKAMURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 BRIDLE TRL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2906
Mailing Address - Country:US
Mailing Address - Phone:719-252-1064
Mailing Address - Fax:
Practice Address - Street 1:4112 OUTLOOK BLVD STE 37
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1667
Practice Address - Country:US
Practice Address - Phone:719-562-6254
Practice Address - Fax:719-562-6255
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44158207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28624777Medicaid
MNP00031174OtherMEDICARE RAILROAD
COC806032Medicare PIN
COH24977Medicare UPIN