Basic Information
| Provider Information | |||||||||
| NPI: | 1467447169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | NELSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043650966 | ||||||||
| FaxNumber: | 6206692394 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PKWY | ||||||||
| Address2: | KAISER PERMANENTE GLENLAKE | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303283473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206626000 | ||||||||
| FaxNumber: | 6206692394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 07001087A | IN | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 36003364M | OH | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | POD001209 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2578974 | 05 | OH | MEDICAID | 200952390 | 05 | IN | MEDICAID |