Provider Demographics
NPI:1992217020
Name:PARISH, SHANE D (MSN, APRN AGNP-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:D
Last Name:PARISH
Suffix:
Gender:M
Credentials:MSN, APRN AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 WOODLAKE DR STE 111
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5740
Mailing Address - Country:US
Mailing Address - Phone:314-645-6840
Mailing Address - Fax:314-628-1046
Practice Address - Street 1:1585 WOODLAKE DR STE 111
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5740
Practice Address - Country:US
Practice Address - Phone:314-645-6840
Practice Address - Fax:314-628-1046
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017038120363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care