Healthcare Provider Details

I. General information

NPI: 1003172784
Provider Name (Legal Business Name): MARGERY ANN SHANE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 03/07/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 HYLAN BOULEVARD SUITE C
STATEN ISLAND NY
10306-4344
US

IV. Provider business mailing address

2627 HYLAN BOULEVARD SUITE C
STATEN ISLAND NY
10306-4344
US

V. Phone/Fax

Practice location:
  • Phone: 718-351-1136
  • Fax: 718-667-9711
Mailing address:
  • Phone: 718-351-1136
  • Fax: 718-667-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF337115-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF337115
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: