1508753815 NPI number — SHAWN THOMAS WELLINGTON-NORTON

Table of content: SHAWN THOMAS WELLINGTON-NORTON (NPI 1508753815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508753815 NPI number — SHAWN THOMAS WELLINGTON-NORTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLINGTON-NORTON
Provider First Name:
SHAWN
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1508753815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6322 KOLTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13440-7507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-761-7046
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5584 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERONA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13478-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-473-3300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2025

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: 163W00000X , with the licence number:  688717-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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