Basic Information
| Provider Information | |||||||||
| NPI: | 1558450031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANLEY | ||||||||
| FirstName: | LETICIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SANTA ROSA | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107043030 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 315 N SAN SABA STE 1135 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107043030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 41989 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | N6995 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 437639 | 05 | AZ | MEDICAID |