Basic Information
| Provider Information | |||||||||
| NPI: | 1538834833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 912 1ST ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052249777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 912 1ST ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052249777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2021 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 1144 | NM | Y |
No ID Information.