Provider Demographics
NPI:1740523828
Name:PEOT, SHANE MICHAEL (RN)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MICHAEL
Last Name:PEOT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-1835
Mailing Address - Country:US
Mailing Address - Phone:920-609-9883
Mailing Address - Fax:
Practice Address - Street 1:1030 COUNTRYSIDE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1835
Practice Address - Country:US
Practice Address - Phone:920-609-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI168533-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse