Individual
SHANA NISENBAUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
1100 CENTRAL AVE SE, ALBUQUERQUE, NM 87106-4930
(505) 724-7044
(505) 841-1462
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
A-1948-16
NM
390200000X
Student in an Organized Health Care Education/Training Program
R09-2013
NM
Other
Enumeration date
03/27/2013
Last updated
06/30/2016
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