Provider Demographics
NPI:1124564950
Name:EXUM, MICHAEL SHANE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:EXUM
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 1:2501 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1735
Mailing Address - Country:US
Mailing Address - Phone:229-244-6852
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-244-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210620367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered