Provider Demographics
NPI:1487806808
Name:BROCK, SHANE (CNP)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 S DON ROSER DR
Mailing Address - Street 2:LAS CRUCES VA CBOC
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4550
Mailing Address - Country:US
Mailing Address - Phone:575-522-1241
Mailing Address - Fax:
Practice Address - Street 1:1635 S DON ROSER DR
Practice Address - Street 2:LAS CRUCES VA CBOC
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4550
Practice Address - Country:US
Practice Address - Phone:575-522-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01132/R46618363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care