Provider Demographics
NPI:1568521896
Name:SHARDLOW, TYSON (DC)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:
Last Name:SHARDLOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LISBON FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04252-1230
Mailing Address - Country:US
Mailing Address - Phone:207-353-6310
Mailing Address - Fax:207-353-4074
Practice Address - Street 1:694 LISBON ST
Practice Address - Street 2:
Practice Address - City:LISBON FALLS
Practice Address - State:ME
Practice Address - Zip Code:04252-1230
Practice Address - Country:US
Practice Address - Phone:207-353-6310
Practice Address - Fax:207-353-4074
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME048519OtherBLUECROSS-BLUESHIELD
MEAA22147OtherHARVARD PILGRIM
ME421290099Medicaid