Provider Demographics
NPI:1013199330
Name:WIBLE, SHANE MARTIN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MARTIN
Last Name:WIBLE
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 E BROWNING AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2025
Mailing Address - Country:US
Mailing Address - Phone:650-619-8618
Mailing Address - Fax:
Practice Address - Street 1:60 MERRITT BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2990
Practice Address - Country:US
Practice Address - Phone:845-905-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6792106-1206363A00000X
NMPA2013-0029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBD210ZMedicare PIN