Provider Demographics
NPI:1215998331
Name:LASTER, SHANE F (OD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:F
Last Name:LASTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 S 36TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8880
Mailing Address - Country:US
Mailing Address - Phone:479-242-2020
Mailing Address - Fax:479-242-1919
Practice Address - Street 1:8500 S 36TH TER
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8880
Practice Address - Country:US
Practice Address - Phone:479-242-2020
Practice Address - Fax:479-242-1919
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2427152W00000X
OK2135152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130679722Medicaid
OK100764560AMedicaid
T20141Medicare UPIN
AR4351100001Medicare NSC
OK100764560AMedicaid