Provider Demographics
NPI:1548868474
Name:BRAGG, SHANE EDWARD
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:EDWARD
Last Name:BRAGG
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:PO BOX 2091
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-2091
Mailing Address - Country:US
Mailing Address - Phone:304-222-1156
Mailing Address - Fax:
Practice Address - Street 1:1520 IRISH MTN RD
Practice Address - Street 2:
Practice Address - City:SHADY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25918
Practice Address - Country:US
Practice Address - Phone:304-222-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant