Healthcare Provider Details

I. General information

NPI: 1033699483
Provider Name (Legal Business Name): SHELBY KATRINA NICOSIA-MURPHY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-4374
US

IV. Provider business mailing address

5904 HOLLY AVE NE
ALBUQUERQUE NM
87113-2472
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5551
  • Fax: 505-272-6845
Mailing address:
  • Phone: 505-298-2505
  • Fax: 505-298-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberPA2018-0053
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA2018-0053
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: