Healthcare Provider Details

I. General information

NPI: 1952815532
Provider Name (Legal Business Name): SHANE MARTIN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SHANE MARTIN RN

II. Dates (important events)

Enumeration Date: 11/19/2017
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 AUGUSTA ST
EUGENE OR
97403-2202
US

IV. Provider business mailing address

2110 AUGUSTA ST
EUGENE OR
97403-2202
US

V. Phone/Fax

Practice location:
  • Phone: 405-630-5159
  • Fax:
Mailing address:
  • Phone: 405-630-5159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number116346
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201810779RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: