Healthcare Provider Details

I. General information

NPI: 1477093375
Provider Name (Legal Business Name): SHANE URBAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE
AURORA CO
80045-7106
US

IV. Provider business mailing address

1253 UINTA ST
DENVER CO
80220-3334
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-4747
  • Fax:
Mailing address:
  • Phone: 303-594-3526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1630029
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: