Provider Demographics
NPI:1639217359
Name:SHACKELFORD, JAMES RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RYAN
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1525 S OWYHEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6014
Mailing Address - Country:US
Mailing Address - Phone:208-297-3698
Mailing Address - Fax:208-561-8051
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANONE207Q00000X, 2084P0800X
IDM-133012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine