Provider Demographics
NPI:1457825556
Name:DUNAWAY, SHANE PAUL (APN)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:PAUL
Last Name:DUNAWAY
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2070
Mailing Address - Country:US
Mailing Address - Phone:731-661-9825
Mailing Address - Fax:731-668-6757
Practice Address - Street 1:24 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2070
Practice Address - Country:US
Practice Address - Phone:731-661-9825
Practice Address - Fax:731-668-6757
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25357363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner