Provider Demographics
NPI:1891455507
Name:PHILLIBER, SHANE ALLAN (CNP)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ALLAN
Last Name:PHILLIBER
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14741 TULSA LN
Mailing Address - Street 2:
Mailing Address - City:STARK CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64866-7964
Mailing Address - Country:US
Mailing Address - Phone:417-638-5183
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-6200
Practice Address - Fax:417-782-3084
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021049273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily