Provider Demographics
NPI:1982471470
Name:LIPSCOMB, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:LIPSCOMB
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 1:909 RIDGEBROOK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9477
Mailing Address - Country:US
Mailing Address - Phone:443-483-9300
Mailing Address - Fax:
Practice Address - Street 1:905 TOWER RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-3116
Practice Address - Country:US
Practice Address - Phone:443-383-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01333200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily