Provider Demographics
NPI:1578674842
Name:SHADOAN, JAMES MARK (EDD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK
Last Name:SHADOAN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 LINKHORNE DR
Mailing Address - Street 2:STE B
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3321
Mailing Address - Country:US
Mailing Address - Phone:434-384-1594
Mailing Address - Fax:434-384-3228
Practice Address - Street 1:2811 LINKHORNE DR
Practice Address - Street 2:STE B
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-3321
Practice Address - Country:US
Practice Address - Phone:434-384-1594
Practice Address - Fax:434-384-3228
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904001247104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA326052OtherANTHEM