Provider Demographics
NPI:1013967249
Name:SHANE, AMBER M (DPM)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:M
Last Name:SHANE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:M
Other - Last Name:SHANE-REEVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:3165 MCCRORY PL
Mailing Address - Street 2:STE 174
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3727
Mailing Address - Country:US
Mailing Address - Phone:407-423-1234
Mailing Address - Fax:407-517-1040
Practice Address - Street 1:250 N ALAFAYA TRL
Practice Address - Street 2:STE 115
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4315
Practice Address - Country:US
Practice Address - Phone:407-447-1020
Practice Address - Fax:407-447-1239
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3200213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00431274OtherRAIL ROAD MEDICARE
FL340576100Medicaid
FL340576100Medicaid
FLU7744ZMedicare PIN