Provider Demographics
NPI:1053140459
Name:LAMBERT, SHANE MICHAEL
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:LAMBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 VALLEY MANOR LN
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26419-8252
Mailing Address - Country:US
Mailing Address - Phone:304-815-1844
Mailing Address - Fax:
Practice Address - Street 1:107 VALLEY MANOR LN
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:WV
Practice Address - Zip Code:26419-8252
Practice Address - Country:US
Practice Address - Phone:304-815-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV125553494Medicaid