Provider Demographics
NPI:1831483536
Name:COOK, SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PENNSYLVANIA AVE STE 213
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-2365
Mailing Address - Country:US
Mailing Address - Phone:515-224-1414
Mailing Address - Fax:515-224-5140
Practice Address - Street 1:1301 PENNSYLVANIA AVE STE 213
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2365
Practice Address - Country:US
Practice Address - Phone:515-224-1414
Practice Address - Fax:515-224-5140
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA44405207X00000X, 207XS0106X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1831483536Medicaid
NCNCS345AMedicare PIN
NCNCS345AMedicare PIN
NC1831483536Medicaid