Provider Demographics
NPI:1861425209
Name:MOIN, SHABANA (MD)
Entity type:Individual
Prefix:
First Name:SHABANA
Middle Name:
Last Name:MOIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 W BULLARD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0861
Mailing Address - Country:US
Mailing Address - Phone:559-297-1300
Mailing Address - Fax:559-324-7534
Practice Address - Street 1:255 W BULLARD AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0861
Practice Address - Country:US
Practice Address - Phone:559-297-1300
Practice Address - Fax:559-324-7534
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA79703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP58392Medicare UPIN