Provider Demographics
NPI:1154813764
Name:SUNDLIE, SHANE MEGAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MEGAN
Last Name:SUNDLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2399
Mailing Address - Country:US
Mailing Address - Phone:910-592-6011
Mailing Address - Fax:910-592-0819
Practice Address - Street 1:403 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2399
Practice Address - Country:US
Practice Address - Phone:910-592-6011
Practice Address - Fax:910-592-0819
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-01125208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics