Provider Demographics
NPI:1649081126
Name:CALLAHAN, SHANE CHARLES
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:CHARLES
Last Name:CALLAHAN
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:PO BOX 948
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0948
Mailing Address - Country:US
Mailing Address - Phone:918-315-4207
Mailing Address - Fax:
Practice Address - Street 1:1305 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-7802
Practice Address - Country:US
Practice Address - Phone:918-682-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty