Provider Demographics
NPI:1578184990
Name:NEWSOM, SHANE (390200000X)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:NEWSOM
Suffix:
Gender:M
Credentials:390200000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12300 MODESTO AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2232
Mailing Address - Country:US
Mailing Address - Phone:505-553-4835
Mailing Address - Fax:
Practice Address - Street 1:12300 MODESTO AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2232
Practice Address - Country:US
Practice Address - Phone:505-553-4835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOtherSTUDENT