Provider Demographics
NPI:1962273854
Name:LOPEZ, SHASTIDY PAULINE (CCSS)
Entity type:Individual
Prefix:
First Name:SHASTIDY
Middle Name:PAULINE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CCSS
Other - Prefix:
Other - First Name:SHASTIDY
Other - Middle Name:PAULINE
Other - Last Name:MADRID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 45681
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-5681
Mailing Address - Country:US
Mailing Address - Phone:505-226-1960
Mailing Address - Fax:505-672-7769
Practice Address - Street 1:1 CAMINO ORO CT
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-7924
Practice Address - Country:US
Practice Address - Phone:706-593-8731
Practice Address - Fax:706-593-8732
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider