Provider Demographics
NPI:1386971042
Name:SKINNER, SHAWN W (OD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:W
Last Name:SKINNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5075 MORGANTON RD STE 9B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1589
Mailing Address - Country:US
Mailing Address - Phone:910-867-2325
Mailing Address - Fax:910-867-2730
Practice Address - Street 1:5075 MORGANTON RD STE 9B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1589
Practice Address - Country:US
Practice Address - Phone:910-867-2325
Practice Address - Fax:910-867-2730
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2399152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0708818OtherPACIFIC UNIVERSITY COLLEGE OF OPTOMETRY