Individual
MR. SHANE SULLAWAY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2100 N HIGHWAY 360, STE. 1802, GRAND PRAIRIE, TX 75050-1011
(972) 647-8567
(972) 660-4548
Mailing address
2100 N HIGHWAY 360, STE. 1802, GRAND PRAIRIE, TX 75050-1011
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
247200000X
—
TX
Enumeration date
06/28/2011
Last updated
06/28/2011
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