Provider Demographics
NPI:1679168637
Name:MARTIN, SHANE G (DC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 COOK ST
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4933
Mailing Address - Country:US
Mailing Address - Phone:262-271-1505
Mailing Address - Fax:
Practice Address - Street 1:3800 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5226
Practice Address - Country:US
Practice Address - Phone:262-271-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5624-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI85-1974635Medicaid