Provider Demographics
NPI:1063117893
Name:SHUMWAY, MAVERIK NICHOLAS
Entity type:Individual
Prefix:
First Name:MAVERIK
Middle Name:NICHOLAS
Last Name:SHUMWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N BLUE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-2012
Mailing Address - Country:US
Mailing Address - Phone:435-459-1923
Mailing Address - Fax:
Practice Address - Street 1:910 S 300 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3921
Practice Address - Country:US
Practice Address - Phone:435-678-0590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13396974-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist