Basic Information
| Provider Information | |||||||||
| NPI: | 1366609653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 25107 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 46616 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-36301 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD17494 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1366609653 | 05 | UT | MEDICAID | 200602140A | 05 | KS | MEDICAID | 204734201 | 05 | TX | MEDICAID | 95452761 | 05 | NM | MEDICAID | 1366609653 | 05 | MT | MEDICAID | 1366609653 | 05 | SD | MEDICAID | 84059792913 | 05 | NE | MEDICAID | 621053 | 05 | AZ | MEDICAID | 10025709000 | 05 | NE | MEDICAID | 7100096790 | 05 | KY | MEDICAID | 1366609653 | 05 | WY | MEDICAID | 1366609653 | 05 | CA | MEDICAID | 1366609653 | 05 | NV | MEDICAID | 1366609653 | 05 | IA | MEDICAID | 1679513196 | 05 | UT | MEDICAID | 200424590A | 05 | OK | MEDICAID | 53577710 | 05 | CO | MEDICAID |