Healthcare Provider Details

I. General information

NPI: 1861539652
Provider Name (Legal Business Name): RONALD A SHOCKLEY MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3483 S EASTERN AVE
LAS VEGAS NV
89169-3314
US

IV. Provider business mailing address

3483 S EASTERN AVE
LAS VEGAS NV
89169-3314
US

V. Phone/Fax

Practice location:
  • Phone: 702-309-2311
  • Fax: 702-309-2177
Mailing address:
  • Phone: 702-309-2311
  • Fax: 702-309-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RONALD A SHOCKLEY
Title or Position: OWNER
Credential: MD
Phone: 702-309-2311