Provider Demographics
NPI:1538817036
Name:DATUGAN, SHANE IZON
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:IZON
Last Name:DATUGAN
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 1:4106 ROSEWOOD DRIVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:JOINT BASE ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3259 CATLIN AVE
Practice Address - Street 2:
Practice Address - City:QUANTICO
Practice Address - State:VA
Practice Address - Zip Code:22134-5109
Practice Address - Country:US
Practice Address - Phone:703-784-1725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant