Provider Demographics
NPI:1457466823
Name:SHANLEY, THERESA JOANNE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JOANNE
Last Name:SHANLEY
Suffix:
Gender:F
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:PO BOX 70378
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-0378
Mailing Address - Country:US
Mailing Address - Phone:907-456-2784
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5925
Practice Address - Country:US
Practice Address - Phone:907-458-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK55332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD7338Medicaid
160245Medicare ID - Type Unspecified
I28245Medicare UPIN