Provider Demographics
NPI:1720444508
Name:GOBLIRSCH, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:GOBLIRSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11381 53RD ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-3902
Mailing Address - Country:US
Mailing Address - Phone:763-213-7378
Mailing Address - Fax:
Practice Address - Street 1:303 CATLIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1947
Practice Address - Country:US
Practice Address - Phone:763-213-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2533OtherBOARD OF MEDICAL PRACTICE