Provider Demographics
NPI:1922696590
Name:STROM, SHANE DYLAN
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:DYLAN
Last Name:STROM
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 1:5641 N MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1639
Mailing Address - Country:US
Mailing Address - Phone:636-541-8924
Mailing Address - Fax:
Practice Address - Street 1:3437 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1111
Practice Address - Country:US
Practice Address - Phone:314-977-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program