Provider Demographics
NPI:1932152873
Name:SHANER, MARIE L (PA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:SHANER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:L
Other - Last Name:CRUCITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 854
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0854
Mailing Address - Country:US
Mailing Address - Phone:800-233-4082
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:800-233-4082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P82485Medicare UPIN
PA82964Medicare ID - Type Unspecified