MEDICARE: MR. SHANE V. MOISIO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	44961	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487601720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE V. MOISIO MD

Provider Business Mailing Address
First Line	:	1919 W NORTH AVE STE 200
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1101
Country	:	US
Telephone Number	:	414-257-7610
Fax Number	:	414-266-3735

Provider Business Practice Location Address
First Line	:	1919 W NORTH AVE STE 200
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1101
Country	:	US
Telephone Number	:	414-257-7610
Fax Number	:	414-266-3735

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2006
Last Update Date	:	01/13/2025

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