Provider Demographics
NPI:1083150064
Name:JAMISON, SHANE (DNP)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:JAMISON
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12809 DIAMOND LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-4155
Mailing Address - Country:US
Mailing Address - Phone:918-721-3264
Mailing Address - Fax:
Practice Address - Street 1:12809 DIAMOND LN
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-4155
Practice Address - Country:US
Practice Address - Phone:918-721-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC003202367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered