Provider Demographics
NPI:1225769730
Name:MIKESKY, SHANE (RD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MIKESKY
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3832 LA CHARLES DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4116
Mailing Address - Country:US
Mailing Address - Phone:317-650-7234
Mailing Address - Fax:
Practice Address - Street 1:2050A 2ND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-7220
Practice Address - Country:US
Practice Address - Phone:505-846-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86174678133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered