Healthcare Provider Details

I. General information

NPI: 1780349449
Provider Name (Legal Business Name): SHEFIU SHONIBARE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2021
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15015 CANYON PARK VIEW DR
CYPRESS TX
77433-1555
US

IV. Provider business mailing address

15015 CANYON PARK VIEW DR
CYPRESS TX
77433-1555
US

V. Phone/Fax

Practice location:
  • Phone: 612-222-0410
  • Fax:
Mailing address:
  • Phone: 612-222-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number40598162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: