Provider Demographics
NPI:1508185828
Name:THORESON, SHANE E (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:E
Last Name:THORESON
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 1:708 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66508-1338
Mailing Address - Country:US
Mailing Address - Phone:785-562-2311
Mailing Address - Fax:785-562-2348
Practice Address - Street 1:808 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66508-1358
Practice Address - Country:US
Practice Address - Phone:785-562-2303
Practice Address - Fax:785-562-2304
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-07393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine