Provider Demographics
NPI:1720009814
Name:MANE, SHEILA R (MD)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:R
Last Name:MANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 E ANDY DEVINE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-3412
Mailing Address - Country:US
Mailing Address - Phone:928-681-3960
Mailing Address - Fax:928-692-0067
Practice Address - Street 1:3535 E ANDY DEVINE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-3412
Practice Address - Country:US
Practice Address - Phone:928-681-3960
Practice Address - Fax:928-692-0067
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ474742Medicaid
AZ474742Medicaid
63051Medicare ID - Type Unspecified