1003066853 NPI number — MR. SHANE MARLON PEDERSON P.T.

Table of content: MR. SHANE MARLON PEDERSON P.T. (NPI 1003066853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003066853 NPI number — MR. SHANE MARLON PEDERSON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSON
Provider First Name:
SHANE
Provider Middle Name:
MARLON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003066853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 WEST MILE 3 ROAD
Provider Second Line Business Mailing Address:
SUITE A-103
Provider Business Mailing Address City Name:
PALMHURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-585-9889
Provider Business Mailing Address Fax Number:
956-585-9896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 WEST MILE 3 ROAD
Provider Second Line Business Practice Location Address:
SUITE A-103
Provider Business Practice Location Address City Name:
PALMHURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-585-9889
Provider Business Practice Location Address Fax Number:
956-585-9896
Provider Enumeration Date:
09/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1155757 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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