Provider Demographics
NPI:1265297097
Name:JAVA, SHAUN CHRISTIAN
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:CHRISTIAN
Last Name:JAVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12124 W COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-5829
Mailing Address - Country:US
Mailing Address - Phone:602-299-4548
Mailing Address - Fax:
Practice Address - Street 1:19829 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4001
Practice Address - Country:US
Practice Address - Phone:623-879-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-06-07
Deactivation Date:2024-04-26
Deactivation Code:
Reactivation Date:2024-05-28
Provider Licenses
StateLicense IDTaxonomies
AZRN174293163W00000X
AZ306567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse