Provider Demographics
NPI:1710422803
Name:MADER, SHAUN (RT(T))
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:MADER
Suffix:
Gender:M
Credentials:RT(T)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 YORK AVE S
Mailing Address - Street 2:#210
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4741
Mailing Address - Country:US
Mailing Address - Phone:612-598-6936
Mailing Address - Fax:
Practice Address - Street 1:7320 YORK AVE S APT 210
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4715
Practice Address - Country:US
Practice Address - Phone:612-598-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCTT-015162471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy