Provider Demographics
NPI:1275007791
Name:STANLEY, SHAYNE TYLER
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:TYLER
Last Name:STANLEY
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 1:2211 PACIFIC BEACH DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5626
Mailing Address - Country:US
Mailing Address - Phone:661-794-0954
Mailing Address - Fax:
Practice Address - Street 1:2600 DODSON ST STE 3
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4432
Practice Address - Country:US
Practice Address - Phone:661-794-0954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD9195737OtherDRIVER LICENSE