Provider Demographics
NPI:1215409115
Name:SHANK, PAUL ALEXANDER
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALEXANDER
Last Name:SHANK
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 1:9 HANOVER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1312
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:
Practice Address - Street 1:85 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1537
Practice Address - Country:US
Practice Address - Phone:603-448-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0377550Medicaid