Provider Demographics
NPI:1417129453
Name:SANUCCI, SHAUN (DO)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:SANUCCI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SHADOW LANE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4194
Mailing Address - Country:US
Mailing Address - Phone:702-388-4000
Mailing Address - Fax:702-388-8431
Practice Address - Street 1:3930 FOURTH AVE
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3119
Practice Address - Country:US
Practice Address - Phone:619-297-9610
Practice Address - Fax:619-297-2244
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL0528207R00000X
CA12677207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine