Provider Demographics
NPI:1417150962
Name:SHETLAR, CHRISTINA ROBYN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ROBYN
Last Name:SHETLAR
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 1:640 QUANTUM RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4506
Mailing Address - Country:US
Mailing Address - Phone:505-924-0209
Mailing Address - Fax:505-924-0210
Practice Address - Street 1:640 QUANTUM RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4506
Practice Address - Country:US
Practice Address - Phone:505-924-0209
Practice Address - Fax:505-924-0210
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN6019207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0022469OtherINSTITUTIONAL PERMIT