Provider Demographics
NPI:1083016034
Name:RATHMANN, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RATHMANN
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 1:4101 W UNION HILLS DR
Mailing Address - Street 2:2018
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1729
Mailing Address - Country:US
Mailing Address - Phone:602-561-4813
Mailing Address - Fax:
Practice Address - Street 1:4101 W UNION HILLS DR
Practice Address - Street 2:2018
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1729
Practice Address - Country:US
Practice Address - Phone:602-561-4813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14-478246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant