Provider Demographics
NPI:1275991366
Name:SHANER, CAMERON
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:SHANER
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 1:840 MADISON AVE SUITE 102
Mailing Address - Street 2:
Mailing Address - City:2068550955
Mailing Address - State:WA
Mailing Address - Zip Code:98110
Mailing Address - Country:US
Mailing Address - Phone:206-855-0955
Mailing Address - Fax:
Practice Address - Street 1:840 MADISON AVE N STE 102
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1769
Practice Address - Country:US
Practice Address - Phone:206-855-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60334924225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist