Provider Demographics
NPI:1306977467
Name:SHANE, MARK R (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:SHANE
Suffix:
Gender:M
Credentials:DC
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Mailing Address - Street 1:1708 STAMPEDE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4829
Mailing Address - Country:US
Mailing Address - Phone:307-587-5591
Mailing Address - Fax:307-587-4399
Practice Address - Street 1:1708 STAMPEDE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4829
Practice Address - Country:US
Practice Address - Phone:307-587-5591
Practice Address - Fax:307-587-4399
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2015-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WY747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY4671132Medicare ID - Type Unspecified