Provider Demographics
NPI:1447434501
Name:GILLEY, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:GILLEY
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 1:1104 CLAUDIA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-3302
Mailing Address - Country:US
Mailing Address - Phone:224-627-3254
Mailing Address - Fax:
Practice Address - Street 1:MSOAG
Practice Address - Street 2:BLDG 202
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-449-9264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman