Provider Demographics
NPI:1508825456
Name:MAXWELL, SHANE A (DO)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1128
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:3551 E OVERLAND RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6757
Practice Address - Country:US
Practice Address - Phone:208-884-1333
Practice Address - Fax:208-489-5188
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0385208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807415700Medicaid
ID1508825456Medicaid
ID807415700Medicaid
1303188Medicare PIN
I21016Medicare UPIN