Provider Demographics
NPI:1326764705
Name:SHADE, STEVEN ANDERSON
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:ANDERSON
Last Name:SHADE
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 1:24230 E 751 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1809
Mailing Address - Country:US
Mailing Address - Phone:918-316-3830
Mailing Address - Fax:
Practice Address - Street 1:1011 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4733
Practice Address - Country:US
Practice Address - Phone:918-525-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist