Provider Demographics
NPI:1104083096
Name:WASDEN, SHANE WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:WILLIAM
Last Name:WASDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 EAST 77TH STREET
Practice Address - Street 2:2 BLACK HALL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1007
Practice Address - Country:US
Practice Address - Phone:212-434-2585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250329207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02299585Medicaid
NYG400088079Medicare UPIN