Provider Demographics
NPI:1720523418
Name:ANDERSON, SHANE DAVID (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:DAVID
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-3105
Mailing Address - Country:US
Mailing Address - Phone:641-200-1165
Mailing Address - Fax:336-900-1572
Practice Address - Street 1:214 S 1ST ST
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-3105
Practice Address - Country:US
Practice Address - Phone:641-200-1165
Practice Address - Fax:336-900-1572
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009250363L00000X, 363LF0000X
ID71001363L00000X
IAA165967363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily