Provider Demographics
NPI:1932665403
Name:SHEA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHEA
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 1:17242 HORIZON TRL SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3939
Mailing Address - Country:US
Mailing Address - Phone:612-380-8301
Mailing Address - Fax:
Practice Address - Street 1:17242 HORIZON TRL SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-3939
Practice Address - Country:US
Practice Address - Phone:612-380-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT010234994001172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver