Provider Demographics
NPI:1184720286
Name:MATHISON, SHANE M (DC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:MATHISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 N. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CADOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54727
Mailing Address - Country:US
Mailing Address - Phone:715-252-8521
Mailing Address - Fax:
Practice Address - Street 1:326 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:CADOTT
Practice Address - State:WI
Practice Address - Zip Code:54727
Practice Address - Country:US
Practice Address - Phone:715-252-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4182-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38965600Medicaid
WI38965600Medicaid