Provider Demographics
NPI:1043606247
Name:SHANE, NATHAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:SHANE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:8591 CROSSROADS DRIVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514
Mailing Address - Country:US
Mailing Address - Phone:330-758-0577
Mailing Address - Fax:330-758-0466
Practice Address - Street 1:8591 CROSSROADS DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514
Practice Address - Country:US
Practice Address - Phone:330-758-0577
Practice Address - Fax:330-758-0466
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111825213ES0103X
IN07001318A213ES0103X
IL016005776213ES0103X
OH36.004061213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery