Individual
SHAYNE TYLER STANLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2600 DODSON ST STE 3, PORT HUENEME, CA 93043-4432
(661) 794-0954
Mailing address
2211 PACIFIC BEACH DR, SAN DIEGO, CA 92109-5626
(661) 794-0954
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
D9195737
DRIVER LICENSE
CA
Enumeration date
01/17/2019
Last updated
01/17/2019
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