Healthcare Provider Details

I. General information

NPI: 1487996427
Provider Name (Legal Business Name): TYLER RAY SHACKELFORD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

IV. Provider business mailing address

4101 INDIAN SCHOOL RD NE STE 110
ALBUQUERQUE NM
87110-3991
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-8206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR06-2013
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA-20176-16
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: