Healthcare Provider Details

I. General information

NPI: 1154021087
Provider Name (Legal Business Name): SHAFAGH BANIHASHEMI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HIGH ST NE
ALBUQUERQUE NM
87102-2565
US

IV. Provider business mailing address

6000 PAPER FLOWER PL NE
ALBUQUERQUE NM
87111-8219
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4444
  • Fax:
Mailing address:
  • Phone: 505-263-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number72300
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: