Basic Information
| Provider Information | |||||||||
| NPI: | 1982217790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMBERSON | ||||||||
| FirstName: | SHAWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 LONG DR STE C | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828013282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076728958 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 DEANNE AVE | ||||||||
| Address2: | |||||||||
| City: | NEWCASTLE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827012936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077464456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | ICPR-008 | WY | Y |
No ID Information.