Provider Demographics
NPI:1073779351
Name:WILLIAMSON, SHANE (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5053 S MCCARRAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5053 S MCCARRAN BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6545
Practice Address - Country:US
Practice Address - Phone:775-853-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6170207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE91603Medicare UPIN