Provider Demographics
NPI:1629399316
Name:THEOBALD, SHANA (MD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MD
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 807
Mailing Address - Street 2:
Mailing Address - City:HANA
Mailing Address - State:HI
Mailing Address - Zip Code:96713-0807
Mailing Address - Country:US
Mailing Address - Phone:808-856-1141
Mailing Address - Fax:
Practice Address - Street 1:4590 HANA HWY
Practice Address - Street 2:
Practice Address - City:HANA
Practice Address - State:HI
Practice Address - Zip Code:96713
Practice Address - Country:US
Practice Address - Phone:808-856-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7901207Q00000X
HI19456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine