Healthcare Provider Details

I. General information

NPI: 1083300016
Provider Name (Legal Business Name): SHAUNTON STUBBS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FLORIDA AVE
MODESTO CA
95350-4422
US

IV. Provider business mailing address

4229 SHAMROCK ST
BOISE ID
83713-2537
US

V. Phone/Fax

Practice location:
  • Phone: 209-573-6183
  • Fax:
Mailing address:
  • Phone: 208-230-3798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: