Individual
SHINEY NATTAKOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
166 ROADRUNNER PKWY, SUITE 1B, LAS CRUCES, NM 88011-7044
(575) 522-2222
(575) 521-3216
Mailing address
PO BOX 1560, LAS CRUCES, NM 88004-1560
(505) 647-8366
(505) 647-8381
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
20050080
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110232565
RR MEDICARE
NM
05
—
50904566
—
NM
01
—
72676
PRESBYTERIAN
NM
01
—
850483184
CHAMPUS
NM
01
—
NM009935
BCBS
NM
Enumeration date
09/02/2005
Last updated
07/19/2011
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