Provider Demographics
NPI:1841289659
Name:ANDERSON, SHANE KEITH (DO)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:KEITH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-0126
Mailing Address - Country:US
Mailing Address - Phone:208-766-2231
Mailing Address - Fax:208-768-4819
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1256
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001424207R00000X
MT11818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000092769OtherPROVIDER NUMBER
MO000092769OtherPROVIDER NUMBER