Provider Demographics
NPI:1194419903
Name:SHAMBLEN, DAVID (PRSS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SHAMBLEN
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SUTHERLAND DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-3309
Mailing Address - Country:US
Mailing Address - Phone:304-400-2630
Mailing Address - Fax:
Practice Address - Street 1:114 SUTHERLAND DR
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-3309
Practice Address - Country:US
Practice Address - Phone:304-400-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty