Provider Demographics
NPI:1467976233
Name:SHANKS, JAMIE PATRICK
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:PATRICK
Last Name:SHANKS
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 1:5410 SUN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-2135
Mailing Address - Country:US
Mailing Address - Phone:850-346-1515
Mailing Address - Fax:
Practice Address - Street 1:5410 SUN VALLEY DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-2135
Practice Address - Country:US
Practice Address - Phone:850-346-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications