Provider Demographics
NPI:1487401386
Name:TRACEY, SHANE PATRICK (NBC-HWC)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:PATRICK
Last Name:TRACEY
Suffix:
Gender:M
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-5140
Mailing Address - Country:US
Mailing Address - Phone:541-206-2271
Mailing Address - Fax:541-470-8729
Practice Address - Street 1:315 W BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3081
Practice Address - Country:US
Practice Address - Phone:541-206-2271
Practice Address - Fax:541-470-8729
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA-3922969171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach