Basic Information
| Provider Information | |||||||||
| NPI: | 1134118995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALENZUELA | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | PATRICE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13634 N. 93RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239330301 | ||||||||
| FaxNumber: | 6239330224 | ||||||||
| Practice Location | |||||||||
| Address1: | 13634 N. 93RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239330301 | ||||||||
| FaxNumber: | 6239330224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 22718 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | BY4334289 | 01 | AZ | DEA | OTHER | 22718 | 01 | AZ | STATE LICENSE | OTHER | 380113 | 05 | AZ | MEDICAID |