Individual
SHANE NEWSOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
390200000X
Contact information
Practice address
12300 MODESTO AVE NE, ALBUQUERQUE, NM 87122-2232
(505) 553-4835
Mailing address
12300 MODESTO AVE NE, ALBUQUERQUE, NM 87122-2232
(505) 553-4835
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
390200000X
STUDENT
—
Enumeration date
04/27/2020
Last updated
04/27/2020
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