Healthcare Provider Details

I. General information

NPI: 1184915407
Provider Name (Legal Business Name): SHAYNE POULIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAYNE THOMPSON

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1873 COMMERCENTER W
SAN BERNARDINO CA
92408-3303
US

IV. Provider business mailing address

700 S TUSTIN ST
ORANGE CA
92866-3425
US

V. Phone/Fax

Practice location:
  • Phone: 909-890-5511
  • Fax: 866-886-7824
Mailing address:
  • Phone: 714-922-4100
  • Fax: 866-886-7824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number260709
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number146174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: