Basic Information
| Provider Information | |||||||||
| NPI: | 1184794349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2559 MEDICAL DR | ||||||||
| Address2: | STE D | ||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883108704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754342229 | ||||||||
| FaxNumber: | 5754395705 | ||||||||
| Practice Location | |||||||||
| Address1: | FORT DEFIANCE PHS HOSPITAL | ||||||||
| Address2: | CORNER OF ROUTE N12 & N7 | ||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A-2192-18 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 3715 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 640921 | 05 | AZ | MEDICAID | 54834864 | 05 | NM | MEDICAID |