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General NPI Number Information
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NPI Number | 1700466950
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Entity Type | Individual
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Provider Name | SHANDIIN ALLURA SAM
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Gender | Female
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Dates
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Enumeration Date | 04/12/2021
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | MSC 09 5040 1 UNIVERSITY OF NEW MEXICO
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City | ALBUQUERQUE
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State | NM
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Zip | 87131-0001
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Country | US
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Telephone | 505-994-5300
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Fax |
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Provider Business Mailing Address
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Address Line | 412 HASTIN NEZ
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City | CAMP VERDE
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State | AZ
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Zip | 86322-8244
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | NM
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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 | 73786
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License Number State | AZ
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