Healthcare Provider Details

I. General information

NPI: 1144535980
Provider Name (Legal Business Name): SHANA PUTNAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANA WANG

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

523 EMERSON ST
UPLAND CA
91784-1341
US

V. Phone/Fax

Practice location:
  • Phone: 909-724-2321
  • Fax:
Mailing address:
  • Phone: 626-235-3845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: