Healthcare Provider Details

I. General information

NPI: 1649494873
Provider Name (Legal Business Name): SHAWN ELLIOT SULAK D.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD STE 407
SANTA FE NM
87507-2653
US

IV. Provider business mailing address

3600 CERRILLOS RD. SUITE 407
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-8990
  • Fax: 505-424-6377
Mailing address:
  • Phone: 505-424-8990
  • Fax: 505-424-6377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number181000316
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number0022
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: