Healthcare Provider Details

I. General information

NPI: 1942287628
Provider Name (Legal Business Name): SHIRLEY BLANCAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 S COUNTRY CLUB RD STE 130
TUCSON AZ
85714-2099
US

IV. Provider business mailing address

3950 S COUNTRY CLUB RD STE 130
TUCSON AZ
85714-2099
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-4800
  • Fax: 520-874-4801
Mailing address:
  • Phone: 520-874-4800
  • Fax: 520-874-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45683-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42772
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: