Healthcare Provider Details

I. General information

NPI: 1316046253
Provider Name (Legal Business Name): SAM SHIESHA MD, FAAFP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25101 BEAR VALLEY RD PMB 347
TEHACHAPI CA
93561-8311
US

IV. Provider business mailing address

25101 BEAR VALLEY RD PMB 347
TEHACHAPI CA
93561-8311
US

V. Phone/Fax

Practice location:
  • Phone: 661-335-2891
  • Fax:
Mailing address:
  • Phone: 661-335-2891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberA46051
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA46051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: