Healthcare Provider Details

I. General information

NPI: 1003286782
Provider Name (Legal Business Name): SHAWN KRISTIAN CENTERS MD(H)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 E ALOE PL
CHANDLER AZ
85286-3109
US

IV. Provider business mailing address

2442 E ALOE PL
CHANDLER AZ
85286-3109
US

V. Phone/Fax

Practice location:
  • Phone: 877-614-4673
  • Fax:
Mailing address:
  • Phone: 619-228-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A7407
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: