Healthcare Provider Details

I. General information

NPI: 1467277426
Provider Name (Legal Business Name): SHONN GREENGRASS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

120 CORNELL DR SE
ALBUQUERQUE NM
87106-3561
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0329
  • Fax:
Mailing address:
  • Phone: 505-639-8093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: