Provider Demographics
NPI:1134118995
Name:VALENZUELA, SHANNON PATRICE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:PATRICE
Last Name:VALENZUELA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13634 N. 93RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-933-0301
Mailing Address - Fax:623-933-0224
Practice Address - Street 1:13634 N. 93RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:623-933-0301
Practice Address - Fax:623-933-0224
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22718207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ22718OtherSTATE LICENSE
AZ380113Medicaid
AZ380113Medicaid
F85978Medicare UPIN
AZ22718OtherSTATE LICENSE