Healthcare Provider Details

I. General information

NPI: 1508421108
Provider Name (Legal Business Name): SHANE MALONE REPT, CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 OLD CREEK DR
TYLER TX
75703-7642
US

IV. Provider business mailing address

1356 OLD CREEK DR
TYLER TX
75703-7642
US

V. Phone/Fax

Practice location:
  • Phone: 903-534-0809
  • Fax: 903-939-9149
Mailing address:
  • Phone: 903-534-0809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number2580
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: