Provider Demographics
NPI:1205447455
Name:THEBERGE, SHAWN (APRN, FNP-C, NR-P)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:THEBERGE
Suffix:
Gender:M
Credentials:APRN, FNP-C, NR-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CANYON WAY
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4895
Mailing Address - Country:US
Mailing Address - Phone:207-650-7540
Mailing Address - Fax:
Practice Address - Street 1:200 W SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9427
Practice Address - Country:US
Practice Address - Phone:207-650-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEP8036707146L00000X
MERN72498163W00000X
MECNP201467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163W00000XNursing Service ProvidersRegistered Nurse