Provider Demographics
NPI:1053767434
Name:SHAN, ELAINE (MD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:SHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 HOWE AVE STE 455
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1086
Mailing Address - Country:US
Mailing Address - Phone:918-407-2495
Mailing Address - Fax:
Practice Address - Street 1:3234 MARYSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-1411
Practice Address - Country:US
Practice Address - Phone:918-407-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58623208000000X
AZR75544208000000X
CAA168601208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics