Healthcare Provider Details

I. General information

NPI: 1376997635
Provider Name (Legal Business Name): ELIZABETH SHANE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 1ST ST
NAPA CA
94559-2841
US

IV. Provider business mailing address

1580 1ST ST
NAPA CA
94559-2841
US

V. Phone/Fax

Practice location:
  • Phone: 707-258-8757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number173299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: