Healthcare Provider Details

I. General information

NPI: 1215409115
Provider Name (Legal Business Name): PAUL ALEXANDER SHANK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MECHANIC ST
LEBANON NH
03766-1537
US

IV. Provider business mailing address

9 HANOVER ST STE 2
LEBANON NH
03766-1312
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-5610
  • Fax:
Mailing address:
  • Phone: 603-448-0126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: