Provider Demographics
NPI:1295168433
Name:ANDERSON, SHANE ROBERT (MBBS, FRACS)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MBBS, FRACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 BEECHWOOD ST, HILLCREST,
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-416-3301
Mailing Address - Fax:
Practice Address - Street 1:1106 BEECHWOOD ST, HILLCREST,
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-416-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-8143207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE-8143OtherARKANSAS STATE LICENSE NUMBER