Healthcare Provider Details

I. General information

NPI: 1275511263
Provider Name (Legal Business Name): RONALD A SHOCKLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
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 Number9492
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: