Provider Demographics
NPI:1053104208
Name:SHANER, JACOB MOSS (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MOSS
Last Name:SHANER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7185 S PASEO MONTE DE ORO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-8368
Mailing Address - Country:US
Mailing Address - Phone:208-473-1097
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 245043
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-5043
Practice Address - Country:US
Practice Address - Phone:520-626-5669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR81861207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology