Healthcare Provider Details

I. General information

NPI: 1184794349
Provider Name (Legal Business Name): SCOTT SHIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FORT DEFIANCE PHS HOSPITAL CORNER OF ROUTE N12 & N7
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

2559 MEDICAL DR STE D
ALAMOGORDO NM
88310-8704
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8770
  • Fax:
Mailing address:
  • Phone: 575-434-2229
  • Fax: 575-439-5705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA-2192-18
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3715
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: