Provider Demographics
NPI:1326660721
Name:CLARY, SHANE MICHAEL (MSN, APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:CLARY
Suffix:
Gender:M
Credentials:MSN, APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 CORBIESHAW RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-4618
Mailing Address - Country:US
Mailing Address - Phone:434-594-4716
Mailing Address - Fax:
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001262949163W00000X
VA0024179611363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse