Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RA0001X | Advanced Heart Failure and Transplant Cardiologist | 2009013305 | MO |
N | 207RC0000X | Internist - Cardiovascular Disease | 2009013305 | MO |
NPI | 1811955180 |
---|---|
Provider Name | Dr. Shane Joseph Larue |
First Address | Hannibal, MO 63401-6877 |
Second Address | Hannibal, MO 63401-6877 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 03/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1811955180 | (05) | MO |
ENROLLED | (05) | IL |