Provider Demographics
NPI:1336747609
Name:BRAIG, SHANE PALMER
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:PALMER
Last Name:BRAIG
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 1:100 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5207
Mailing Address - Country:US
Mailing Address - Phone:405-974-3632
Mailing Address - Fax:
Practice Address - Street 1:5113 SE 15TH ST STE A
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3952
Practice Address - Country:US
Practice Address - Phone:405-600-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist