Healthcare Provider Details

I. General information

NPI: 1235712324
Provider Name (Legal Business Name): NICHOLAS SHANE BARNEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BURRO ALY
MORENCI AZ
85540-9647
US

IV. Provider business mailing address

1000 N LEE AVE RM 1980
OKLAHOMA CITY OK
73102-1036
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-9184
  • Fax:
Mailing address:
  • Phone: 405-272-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number67371
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number67371
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: