Provider Demographics
NPI:1811215288
Name:DUNCAN, SHANE BLAKE (BS)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:BLAKE
Last Name:DUNCAN
Suffix:
Gender:M
Credentials:BS
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 332
Mailing Address - Street 2:
Mailing Address - City:WATTS
Mailing Address - State:OK
Mailing Address - Zip Code:74964-0332
Mailing Address - Country:US
Mailing Address - Phone:918-422-4888
Mailing Address - Fax:
Practice Address - Street 1:202 S. MAIN
Practice Address - Street 2:
Practice Address - City:WATTS
Practice Address - State:OK
Practice Address - Zip Code:74965-0332
Practice Address - Country:US
Practice Address - Phone:918-422-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator