Provider Demographics
NPI:1811602543
Name:MYINT, SHANE MAUNG (FNP-C)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MAUNG
Last Name:MYINT
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 1:8724 STODDARD LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-1005
Mailing Address - Country:US
Mailing Address - Phone:317-250-1022
Mailing Address - Fax:
Practice Address - Street 1:610 E SOUTHPORT RD STE 205
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8592
Practice Address - Country:US
Practice Address - Phone:317-781-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014038A363LF0000X
IN28183366A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse