=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013967249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER M SHANE DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 09/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 N ALAFAYA TRL STE 115
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32828-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-447-1020
-----------------------------------------------------
Fax | 407-447-1239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3165 MCCRORY PL STE 174
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-423-1234
-----------------------------------------------------
Fax | 407-517-1040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO 3200
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------