Provider Demographics
NPI:1952412652
Name:HERNESMAN, SHANE CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:CHRISTOPHER
Last Name:HERNESMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S COURTENAY PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4977
Mailing Address - Country:US
Mailing Address - Phone:321-453-5888
Mailing Address - Fax:
Practice Address - Street 1:650 S COURTENAY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4977
Practice Address - Country:US
Practice Address - Phone:321-453-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG83792Medicare UPIN
FL06019Medicare ID - Type Unspecified