Healthcare Provider Details

I. General information

NPI: 1225770365
Provider Name (Legal Business Name): LISA S SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2022
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 ST MICHAELS DR STE 200 FAMILY MEDICINE
SANTA FE NM
87505-7602
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-5000
  • Fax: 505-303-5202
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2026-0033
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: