Provider Demographics
NPI:1467189571
Name:WILLIAMS, SHANE JAXYN LOGEN
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:JAXYN LOGEN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 ASH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1536
Mailing Address - Country:US
Mailing Address - Phone:681-588-7733
Mailing Address - Fax:
Practice Address - Street 1:206 ASH AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-1536
Practice Address - Country:US
Practice Address - Phone:681-588-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV125553494Medicaid