Provider Demographics
NPI:1548917875
Name:PRESTON, SHANE (NP)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:PRESTON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:336 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5418
Mailing Address - Country:US
Mailing Address - Phone:781-605-8158
Mailing Address - Fax:
Practice Address - Street 1:100 BROOKSBY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-1438
Practice Address - Country:US
Practice Address - Phone:978-536-7870
Practice Address - Fax:978-536-7997
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2324877363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health