Healthcare Provider Details

I. General information

NPI: 1144208661
Provider Name (Legal Business Name): SHANE BLAKE ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5334 S WOODROW ST STE 100
MURRAY UT
84107-5838
US

IV. Provider business mailing address

5334 S WOODROW ST STE 100
MURRAY UT
84107-5838
US

V. Phone/Fax

Practice location:
  • Phone: 801-713-0600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number328507-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number378
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number328507-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: