Individual
MR. SHANE A MAXWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
3551 E OVERLAND RD, MERIDIAN, ID 83642-6757
(208) 884-1333
(208) 489-5188
Mailing address
PO BOX 1128, BOISE, ID 83701-1128
(208) 381-2222
(208) 463-3044
Taxonomy
Speciality
Code
Description
License number
State
208VP0014X
Interventional Pain Medicine Physician
Primary
O0385
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1508825456
—
ID
05
—
807415700
—
ID
Enumeration date
03/20/2006
Last updated
07/21/2022
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