Basic Information
| Provider Information | |||||||||
| NPI: | 1750522702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAHMOHAMMADI | ||||||||
| FirstName: | SIAMAK | ||||||||
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| Credential: | RPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 EAGLERIDGE BLVD | ||||||||
| Address2: | SUITE #50 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195847415 | ||||||||
| FaxNumber: | 7195427019 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 EAGLERIDGE BLVD | ||||||||
| Address2: | SUITE #50 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195847415 | ||||||||
| FaxNumber: | 7195427019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 03/19/2009 | ||||||||
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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 | 243U00000X | Y | Technologists, Technicians & Other Technical Service Providers | Radiology Practitioner Assistant |
No ID Information.