Basic Information
| Provider Information | |||||||||
| NPI: | 1467865329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 N 1900 E RM 1A07 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817553 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 N 1900 E RM 1A07 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817553 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101021222 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 11085898-1204 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.