Healthcare Provider Details

I. General information

NPI: 1174873087
Provider Name (Legal Business Name): MAMOONA SHAIKH-AHMAD, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 CITY BANK PKWY SUITE 35
LUBBOCK TX
79407-3544
US

IV. Provider business mailing address

PO BOX 64412
LUBBOCK TX
79464-4412
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0334
  • Fax: 806-785-0872
Mailing address:
  • Phone: 806-761-0334
  • Fax: 806-785-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD2005-0851
License Number StateNM

VIII. Authorized Official

Name: KELLY FISCHER
Title or Position: CREDENTIALLING COORDINATOR
Credential:
Phone: 806-761-0329