Provider Demographics
NPI:1871615211
Name:RUIZ, SHAWNA L
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:L
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 W SIMMONS RD
Mailing Address - Street 2:#2
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-2635
Mailing Address - Country:US
Mailing Address - Phone:520-777-8880
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:544 W SIMMONS RD
Practice Address - Street 2:#2
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-2635
Practice Address - Country:US
Practice Address - Phone:520-777-8880
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12461171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ194420Medicaid