Provider Demographics
NPI:1639554207
Name:WILSON, SHAYNA
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
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 1068
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MT
Mailing Address - Zip Code:59935-1068
Mailing Address - Country:US
Mailing Address - Phone:406-295-4044
Mailing Address - Fax:
Practice Address - Street 1:304 NORTH 2ND STREET
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MT
Practice Address - Zip Code:59935
Practice Address - Country:US
Practice Address - Phone:406-295-4044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMTLIC2633173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
371665384OtherINS.