Provider Demographics
NPI:1427461706
Name:WINKENWADER, SHANE (ATC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WINKENWADER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 23RD ST E APT B
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:628 23RD ST E APT B
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-2396
Practice Address - Country:US
Practice Address - Phone:701-355-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer