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General NPI Number Information
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NPI Number | 1043949175
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Entity Type | Individual
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Provider Name | SHANE EVANDER MARTIN
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Gender | Male
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Dates
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Enumeration Date | 06/06/2022
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Last Update Date | 03/08/2023
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Provider Practice Location Address
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Address Line | 11835 RT 9W
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City | WEST COXSACKIE
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State | NY
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Zip | 12192-3605
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Country | US
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Telephone | 518-264-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 11835 RT 9W
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City | WEST COXSACKIE
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State | NY
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Zip | 12192-3605
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Country | US
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Telephone | 518-264-9000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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