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General NPI Number Information
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NPI Number | 1073819314
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Entity Type | Individual
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Provider Name | SHANE MARSHALL D.O.
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Gender | Male
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Dates
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Enumeration Date | 02/03/2011
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Last Update Date | 10/04/2017
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Provider Practice Location Address
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Address Line | 4813 S 187TH EAST AVE
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City | TULSA
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State | OK
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Zip | 74134-7203
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Country | US
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Telephone | 208-371-5536
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Fax |
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Provider Business Mailing Address
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Address Line | 4813 S 187TH EAST AVE
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City | TULSA
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State | OK
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Zip | 74134-7203
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Country | US
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Telephone | 208-371-5536
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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 | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number | 4925
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | DO184177
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License Number State | OR
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