Provider Demographics
NPI:1003172784
Name:SHANE, MARGERY ANN (NP)
Entity Type:Individual
Prefix:MISS
First Name:MARGERY
Middle Name:ANN
Last Name:SHANE
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:2627 HYLAN BOULEVARD
Mailing Address - Street 2:SUITE C
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4344
Mailing Address - Country:US
Mailing Address - Phone:718-351-1136
Mailing Address - Fax:718-667-9711
Practice Address - Street 1:2627 HYLAN BOULEVARD
Practice Address - Street 2:SUITE C
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4344
Practice Address - Country:US
Practice Address - Phone:718-351-1136
Practice Address - Fax:718-667-9711
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF337115-1363LF0000X
NYF337115363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03442679Medicaid
NYMS2612679OtherDEA
NYMS2612679OtherDEA