Healthcare Provider Details

I. General information

NPI: 1912056847
Provider Name (Legal Business Name): SHANE JARAMILLO HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2839 CARLISLE BLVD NE SUITE 110
ALBUQUERQUE NM
87110-2876
US

IV. Provider business mailing address

2839 CARLISLE BLVD NE SUITE 110
ALBUQUERQUE NM
87110-2876
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-3304
  • Fax: 505-881-1622
Mailing address:
  • Phone: 505-881-3304
  • Fax: 505-881-1622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number502
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: