Provider Demographics
NPI:1790779007
Name:SCHOONOVER, SHELLEY P (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:P
Last Name:SCHOONOVER
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 1:3917 WEST RD
Mailing Address - Street 2:STE 128
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-662-4234
Mailing Address - Fax:505-662-7894
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:STE 128
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-662-4234
Practice Address - Fax:505-662-7894
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93385208000000X
TXJ0249208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51342Medicaid