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General NPI Number Information
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NPI Number | 1134534696
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Entity Type | Individual
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Provider Name | SHANE ETHAN ORR
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Gender | Male
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Dates
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Enumeration Date | 06/24/2014
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Last Update Date | 08/10/2015
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Provider Practice Location Address
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Address Line | 706 S GREATHOUSE DR
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City | ATOKA
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State | OK
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Zip | 74525
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Country | US
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Telephone | 580-889-3553
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Fax | 580-889-4050
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Provider Business Mailing Address
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Address Line | 907 W OHIO AVE
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City | COALGATE
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State | OK
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Zip | 74538-1216
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Country | US
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Telephone | 580-258-0056
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Fax | 580-889-4050
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | OK
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