Healthcare Provider Details

I. General information

NPI: 1104282177
Provider Name (Legal Business Name): SHANE WALLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 GARNET AVE
SAN DIEGO CA
92109-3555
US

IV. Provider business mailing address

1968 GARNET AVE
SAN DIEGO CA
92109-3555
US

V. Phone/Fax

Practice location:
  • Phone: 612-214-1325
  • Fax:
Mailing address:
  • Phone: 619-942-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number310143
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: