Provider Demographics
NPI:1487601720
Name:MOISIO, SHANE V (MD)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:V
Last Name:MOISIO
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1919 W NORTH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1101
Mailing Address - Country:US
Mailing Address - Phone:414-257-7610
Mailing Address - Fax:414-266-3735
Practice Address - Street 1:1919 W NORTH AVE STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-1101
Practice Address - Country:US
Practice Address - Phone:414-257-7610
Practice Address - Fax:414-266-3735
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI449612084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34317100Medicaid