Provider Demographics
NPI:1811142086
Name:CLEMENS, SHANE WESLEY
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:WESLEY
Last Name:CLEMENS
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 1:7609 ALBERT RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MN
Mailing Address - Zip Code:55779-9676
Mailing Address - Country:US
Mailing Address - Phone:218-390-6415
Mailing Address - Fax:
Practice Address - Street 1:7609 ALBERT RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MN
Practice Address - Zip Code:55779-9676
Practice Address - Country:US
Practice Address - Phone:218-390-6415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor