Provider Demographics
NPI:1356473078
Name:BRUBAKER, SHAWN M (DO)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES, 2ND FLOOR
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 AIRPARK DR
Practice Address - Street 2:STE 301
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2449
Practice Address - Country:US
Practice Address - Phone:530-242-3500
Practice Address - Fax:530-242-3546
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9922207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVSL0399OtherNEVADA MEDICAL LICENSE
CA20A9922OtherCA MEDICAL LICENSE
VA0116018251OtherVIRGINIA MEDICAL LICENSE
MI5101015098OtherMICHIGAN MEDICAL LICENSE