Healthcare Provider Details

I. General information

NPI: 1114346129
Provider Name (Legal Business Name): STEPHEN W SHANKS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 160
SHIPROCK NM
87420-0160
US

IV. Provider business mailing address

1643 NW 136TH AVE
SUNRISE FL
33323-3091
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015-01973
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2022-0050
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: