Provider Demographics
NPI:1447525779
Name:BALDERRAMA, SHAVON
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:BALDERRAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAVON
Other - Middle Name:
Other - Last Name:CARRASCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5110
Mailing Address - Country:US
Mailing Address - Phone:575-885-4836
Mailing Address - Fax:575-628-0676
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5896
Practice Address - Country:US
Practice Address - Phone:575-885-0956
Practice Address - Fax:575-234-9854
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator