Provider Demographics
NPI:1619580776
Name:GAMBLE, SHANE (RD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 NW BASCO AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6164
Mailing Address - Country:US
Mailing Address - Phone:774-217-0722
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86058164133V00000X
MA4758133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered