Provider Demographics
NPI:1356308316
Name:ANDREW, SHANE A (DO)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:A
Last Name:ANDREW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-288-4700
Practice Address - Fax:208-288-4720
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0443207X00000X
FLOS9764207X00000X
IDO-0443207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807749400Medicaid
P00413752OtherRAILROAD MEDICARE
1136162Medicare PIN