Provider Demographics
NPI:1407215460
Name:HNATUSKO, SHANE BRODY (MSIV)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:BRODY
Last Name:HNATUSKO
Suffix:
Gender:M
Credentials:MSIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:744 W 9TH ST
Mailing Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9020
Mailing Address - Country:US
Mailing Address - Phone:918-599-5100
Mailing Address - Fax:918-599-5065
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-599-5100
Practice Address - Fax:918-599-5065
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-40483207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine