Provider Demographics
NPI:1225642887
Name:SHINER, MARQUEE JO (LMT)
Entity Type:Individual
Prefix:
First Name:MARQUEE
Middle Name:JO
Last Name:SHINER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:LEMHI
Mailing Address - State:ID
Mailing Address - Zip Code:83465-0023
Mailing Address - Country:US
Mailing Address - Phone:208-303-6616
Mailing Address - Fax:
Practice Address - Street 1:1911 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4512
Practice Address - Country:US
Practice Address - Phone:208-303-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3579225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-3579OtherALL INSURANCES
IDMAS-3579Medicaid