Provider Demographics
NPI:1073197679
Name:TIERNEY, MICHAEL SHANE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 DAVIDSON RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4399
Mailing Address - Country:US
Mailing Address - Phone:703-714-5771
Mailing Address - Fax:
Practice Address - Street 1:1633 DAVIDSON RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4399
Practice Address - Country:US
Practice Address - Phone:703-714-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260017182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer