Healthcare Provider Details

I. General information

NPI: 1871586586
Provider Name (Legal Business Name): DALLAS R SHECKLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8208 LOUISIANA BLVD NE STE C
ALBUQUERQUE NM
87113-1757
US

IV. Provider business mailing address

2510 W DUNLAP AVE STE 290
PHOENIX AZ
85021-2737
US

V. Phone/Fax

Practice location:
  • Phone: 505-858-1222
  • Fax: 505-858-1224
Mailing address:
  • Phone: 602-789-0344
  • Fax: 602-789-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number673
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number99-PA24
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: