Provider Demographics
NPI:1396739579
Name:NATTAKOM, SHINEY (MD)
Entity type:Individual
Prefix:
First Name:SHINEY
Middle Name:
Last Name:NATTAKOM
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:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1560
Mailing Address - Country:US
Mailing Address - Phone:505-647-8366
Mailing Address - Fax:505-647-8381
Practice Address - Street 1:166 ROADRUNNER PKWY
Practice Address - Street 2:SUITE 1B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7044
Practice Address - Country:US
Practice Address - Phone:575-522-2222
Practice Address - Fax:575-521-3216
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20050080207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM009935OtherBCBS
NM850483184OtherCHAMPUS
NM72676OtherPRESBYTERIAN
NM50904566Medicaid
NM110232565OtherRR MEDICARE
NM50904566Medicaid
NMNM400012Medicare PIN