Provider Demographics
NPI:1760501795
Name:SHANG, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:SHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-4005
Mailing Address - Country:US
Mailing Address - Phone:702-370-5430
Mailing Address - Fax:702-675-4501
Practice Address - Street 1:2626 S RAINBOW BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-4005
Practice Address - Country:US
Practice Address - Phone:702-370-5430
Practice Address - Fax:702-675-4501
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV91292083X0100X, 207Q00000X, 209800000X
CODR.0056727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODR.0056727OtherCO LICENSE
NVBK083BMedicare PIN
NVBK083AMedicare PIN
NVCL870ZMedicare UPIN
CODR.0056727OtherCO LICENSE