Provider Demographics
NPI:1134574510
Name:SADDELMIRE, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:SADDELMIRE
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 1:110 HO PLZ
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14853-3102
Mailing Address - Country:US
Mailing Address - Phone:607-255-6106
Mailing Address - Fax:607-254-3503
Practice Address - Street 1:110 HO PLZ
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853-3102
Practice Address - Country:US
Practice Address - Phone:607-255-6106
Practice Address - Fax:607-254-3503
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY649922163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse