Provider Demographics
NPI:1811925803
Name:RAU, SHANE WYATT (MD PHD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:WYATT
Last Name:RAU
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5483 MOORETOWN RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2108
Mailing Address - Country:US
Mailing Address - Phone:757-941-6400
Mailing Address - Fax:757-941-6419
Practice Address - Street 1:5483 MOORETOWN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2108
Practice Address - Country:US
Practice Address - Phone:757-941-6400
Practice Address - Fax:757-941-6419
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012394992084P0800X
NC2008-010202084P0800X
IL0361574082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
163992Medicare UPIN
VA011366C61Medicare ID - Type Unspecified