Provider Demographics
NPI:1336127240
Name:DEGEN, SHANE J (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:J
Last Name:DEGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6089
Mailing Address - Country:US
Mailing Address - Phone:920-430-4700
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6089
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47641207Q00000X
WI50647 - 020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN241127000Medicaid
WI071700060Medicare Oscar/Certification
I40467Medicare UPIN
MN080014432Medicare ID - Type Unspecified
WI075100113Medicare Oscar/Certification
MN241127000Medicaid
WI073050057Medicare Oscar/Certification
WI073100056Medicare Oscar/Certification