Healthcare Provider Details

I. General information

NPI: 1780326470
Provider Name (Legal Business Name): SHAOBO GUAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

234 E 149TH ST
BRONX NY
10451-5504
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6262
  • Fax:
Mailing address:
  • Phone: 844-692-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number339413
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: