Provider Demographics
NPI:1083603229
Name:MCCAULEY, SHANE NATHANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:NATHANIEL
Last Name:MCCAULEY
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 1:3340 E GOLDSTONE DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-7600
Mailing Address - Fax:208-302-7605
Practice Address - Street 1:6051 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-7600
Practice Address - Fax:208-302-7605
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059435A171000000X, 207Q00000X, 2083A0100X
IDM-14730207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine