Provider Demographics
NPI:1841518834
Name:HARRIS, SHANE MARIE (NP)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7952
Mailing Address - Country:US
Mailing Address - Phone:631-323-4355
Mailing Address - Fax:
Practice Address - Street 1:1745 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7952
Practice Address - Country:US
Practice Address - Phone:631-323-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY652556163W00000X
NY291707-1164W00000X
NY312322363LA2200X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism