Healthcare Provider Details

I. General information

NPI: 1083603229
Provider Name (Legal Business Name): SHANE NATHANIEL MCCAULEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W EMERALD ST
BOISE ID
83704
US

IV. Provider business mailing address

3340 E GOLDSTONE DR.
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-7600
  • Fax: 208-302-7605
Mailing address:
  • Phone: 208-302-7600
  • Fax: 208-302-7605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number01059435A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01059435A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-14730
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01059435A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberM-14730
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: