Healthcare Provider Details

I. General information

NPI: 1326044686
Provider Name (Legal Business Name): SHANE K. WOOLF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 N STATE ST STE 120
LOWVILLE NY
13367-1297
US

IV. Provider business mailing address

7785 N STATE ST
LOWVILLE NY
13367-1229
US

V. Phone/Fax

Practice location:
  • Phone: 315-376-4505
  • Fax: 315-376-4259
Mailing address:
  • Phone: 315-376-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2005-0142
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number21387
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number21387
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number319067
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: