Healthcare Provider Details

I. General information

NPI: 1477983849
Provider Name (Legal Business Name): SHELLY ANN MINISH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

IV. Provider business mailing address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-3991
  • Fax: 505-998-1660
Mailing address:
  • Phone: 505-242-3991
  • Fax: 505-998-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2016-0106
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0106
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: