Provider Demographics
NPI:1659319515
Name:ADKISON, SHANE A (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:A
Last Name:ADKISON
Suffix:
Gender:M
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 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-934-7258
Mailing Address - Fax:850-934-7276
Practice Address - Street 1:1399 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3451
Practice Address - Country:US
Practice Address - Phone:850-934-7258
Practice Address - Fax:850-934-7276
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377670100Medicaid
FL27108Medicare ID - Type Unspecified
FLG03857Medicare UPIN