Provider Demographics
NPI:1962035162
Name:MORRIS, SHANE MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MATTHEW
Last Name:MORRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4076 NEELY ROAD
Mailing Address - Street 2:BLDG 4076, ROOM 1B-201
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:907-361-2670
Mailing Address - Fax:
Practice Address - Street 1:4076 NEELY ROAD
Practice Address - Street 2:BLDG 4076 ROOM 1B-201
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:907-361-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-16
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313812-01207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine