Provider Demographics
NPI:1902011893
Name:SHAY, FRED GLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:GLEN
Last Name:SHAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 E DUNBAR DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5799
Mailing Address - Country:US
Mailing Address - Phone:602-232-2178
Mailing Address - Fax:
Practice Address - Street 1:5847 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-3512
Practice Address - Country:US
Practice Address - Phone:602-268-3451
Practice Address - Fax:602-268-9179
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4263111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor