Healthcare Provider Details

I. General information

NPI: 1821812934
Provider Name (Legal Business Name): ELEONORA SHUKSHINA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 NW BURNSIDE RD
GRESHAM OR
97030-3739
US

IV. Provider business mailing address

6760 E NORTHRIDGE ST
MESA AZ
85215-1671
US

V. Phone/Fax

Practice location:
  • Phone: 503-382-8100
  • Fax:
Mailing address:
  • Phone: 602-565-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number263643
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: