Provider Demographics
NPI:1508421108
Name:MALONE, SHANE (REPT, CNIM)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MALONE
Suffix:
Gender:M
Credentials:REPT, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 OLD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-7642
Mailing Address - Country:US
Mailing Address - Phone:903-534-0809
Mailing Address - Fax:
Practice Address - Street 1:1356 OLD CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-7642
Practice Address - Country:US
Practice Address - Phone:903-534-0809
Practice Address - Fax:903-939-9149
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0500X, 246ZS0410X
TX2580246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist