Healthcare Provider Details

I. General information

NPI: 1780666982
Provider Name (Legal Business Name): SHELLEY A KATZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 CANYON BLUFF TRL NE
ALBUQUERQUE NM
87111-8239
US

IV. Provider business mailing address

5400 CANYON BLUFF TRL NE
ALBUQUERQUE NM
87111-8239
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-1029
  • Fax:
Mailing address:
  • Phone: 505-508-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberSK078965
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2012-0788
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: