Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | F337115-1 | NY |
NPI | 1003172784 |
---|---|
Provider Name | Miss Margery Shane |
First Address | Staten Island, NY 10306-2364 |
Second Address | Staten Island, NY 10306-3034 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2012 |
Last Update Date | 19/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03442679 | (05) | NY |
MS2612679 | DEA (01) | NY |