Provider Demographics
NPI:1013083286
Name:CUMMINGS, SHANE W (M D)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:W
Last Name:CUMMINGS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 E DIMOND BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2031
Mailing Address - Country:US
Mailing Address - Phone:907-344-2400
Mailing Address - Fax:907-344-2404
Practice Address - Street 1:1310 E DIMOND BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2031
Practice Address - Country:US
Practice Address - Phone:907-344-2400
Practice Address - Fax:907-344-2404
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5887207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1012003Medicaid