Provider Demographics
NPI:1669899894
Name:AUSTIN, SHANE NICHOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:NICHOLAS
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 RAINBOW BLVD # MS 4010
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:913-588-1902
Mailing Address - Fax:913-588-1951
Practice Address - Street 1:5870 HIATUS RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-6424
Practice Address - Country:US
Practice Address - Phone:954-835-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME132067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program