Provider Demographics
NPI:1316046253
Name:SHIESHA, SAM (MD, FAAFP)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:SHIESHA
Suffix:
Gender:M
Credentials:MD, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25101 BEAR VALLEY RD
Mailing Address - Street 2:PMB 347
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-8311
Mailing Address - Country:US
Mailing Address - Phone:661-335-2891
Mailing Address - Fax:
Practice Address - Street 1:25101 BEAR VALLEY RD
Practice Address - Street 2:PMB 347
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-8311
Practice Address - Country:US
Practice Address - Phone:661-335-2891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46051207QA0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A460510Medicaid
CA00A460510Medicaid