=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538584982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE LAVIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2014
-----------------------------------------------------
Last Update Date | 08/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 LAKEVILLE HWY MOB-2
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-765-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 JOHN PAUL JONES CIR
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23708-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-2518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | 178185
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------