Provider Demographics
NPI:1083649065
Name:BLAISDELL, SHAWN (CFNP, CNM)
Entity Type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:CFNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1001 MEDICAL ARTS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2708
Practice Address - Country:US
Practice Address - Phone:505-272-0457
Practice Address - Fax:505-272-2043
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM425176B00000X
NMR37437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17605717Medicaid
P14910Medicare UPIN
345506301Medicare ID - Type Unspecified