Provider Demographics
NPI:1750857223
Name:SHANKWEILER, MATHEW
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:SHANKWEILER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 53RD AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2960
Mailing Address - Country:US
Mailing Address - Phone:727-249-3307
Mailing Address - Fax:
Practice Address - Street 1:30 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:EAST MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04430-1040
Practice Address - Country:US
Practice Address - Phone:727-249-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion