Provider Demographics
NPI:1497522072
Name:LUTHER, SHAUN MARVIN
Entity Type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:MARVIN
Last Name:LUTHER
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 1:776 W LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4713
Mailing Address - Country:US
Mailing Address - Phone:951-215-8465
Mailing Address - Fax:
Practice Address - Street 1:776 W LONGVIEW AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4713
Practice Address - Country:US
Practice Address - Phone:951-215-8465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA814023390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program