Healthcare Provider Details

I. General information

NPI: 1326660721
Provider Name (Legal Business Name): SHANE MICHAEL CLARY MSN, APRN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 TATE SPRINGS RD
LYNCHBURG VA
24501-1109
US

IV. Provider business mailing address

3122 CORBIESHAW RD SW
ROANOKE VA
24015-4618
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3000
  • Fax:
Mailing address:
  • Phone: 434-594-4716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024179611
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001262949
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: