Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | 25MA10759000 | NJ |
Y | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | DR0065962 | CO |
N | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | MD462106 | PA |
NPI | 1083000541 |
---|---|
Provider Name | Shane Rothermel |
First Address | Egg Harbor Township, NJ 08234-5598 |
Second Address | Pueblo, CO 81008-2215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2015 |
Last Update Date | 30/10/2021 |