Provider Demographics
NPI:1356653729
Name:WALLIS, SHAIN S (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAIN
Middle Name:S
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:5100 WEST TAFT RD
Practice Address - Street 2:STE 2A
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-452-2666
Practice Address - Fax:315-452-2669
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
NY2649572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program