Provider Demographics
NPI:1497749741
Name:SHYNN, TAE I (MD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:I
Last Name:SHYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 SUTTON RD
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9471
Mailing Address - Country:US
Mailing Address - Phone:570-690-4527
Mailing Address - Fax:
Practice Address - Street 1:980 SUTTON RD
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708-9471
Practice Address - Country:US
Practice Address - Phone:570-690-4527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036509L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000000213215OtherUNISON
PA0005531730002Medicaid
PA000000213215OtherUNISON