Healthcare Provider Details

I. General information

NPI: 1487145868
Provider Name (Legal Business Name): SHAYNE LEON SPARROW PARAMEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SHAYNE LEON STOCKTON PARAMEDIC

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE ATTN: MCHJ-CLQ-C
TACOMA WA
98431-0001
US

IV. Provider business mailing address

207 TERRACE CT
VANDENBERG AFB CA
93437-1437
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0940
  • Fax:
Mailing address:
  • Phone: 504-430-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberM0983833
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: