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General NPI Number Information
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NPI Number | 1114346129
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Entity Type | Individual
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Provider Name | STEPHEN W SHANKS DO
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Gender | Male
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Dates
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Enumeration Date | 04/08/2014
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Last Update Date | 06/06/2022
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Provider Practice Location Address
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Address Line | 800 SAGUARO TRL
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City | FARMINGTON
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State | NM
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Zip | 87401-9632
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Country | US
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Telephone | 505-498-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 1643 NW 136TH AVE BLDG H SUITE 100 MSC 11607-0004
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City | SUNRISE
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State | FL
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Zip | 33323-2857
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2015-01973
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DO2022-0050
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License Number State | NM
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