Provider Demographics
NPI:1083300016
Name:STUBBS, SHAUNTON (DO)
Entity Type:Individual
Prefix:
First Name:SHAUNTON
Middle Name:
Last Name:STUBBS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 SHAMROCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2537
Mailing Address - Country:US
Mailing Address - Phone:208-230-3798
Mailing Address - Fax:
Practice Address - Street 1:1400 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4422
Practice Address - Country:US
Practice Address - Phone:209-573-6183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program