Provider Demographics
NPI:1801196985
Name:SHOATNANON, KAM
Entity Type:Individual
Prefix:
First Name:KAM
Middle Name:
Last Name:SHOATNANON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4974 N FRESNO ST # 291
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40044 HIGHWAY 49 STE D
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-8875
Practice Address - Country:US
Practice Address - Phone:559-642-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist