Active NPI
Shane Wallin
- Medical Art Specialist/Technologist
- San Diego, CA
National Provider Identifier
1104282177
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Art Specialist/Technologist
- License
- 310143
- Practice address
- 1968 Garnet Ave
San Diego, CA 92109-3555 - Phone
- (612) 214-1325
- NPI assigned
- Jan 6, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Art Specialist/Technologist | 246ZA2600X | 310143 | MN | Primary |
Addresses
Primary practice location
1968 Garnet Ave
San Diego, CA 92109-3555
Mailing address
1968 Garnet Ave
San Diego, CA 92109-3555
Phone (619) 942-9737
Other practice location 1
3073 Jefferson St
Napa, CA 94558-4921
Phone (619) 942-9737
Other practice location 2
4933 34th Ave S
Minneapolis, MN 55417-1503
Phone (619) 942-9737
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 310143 | MN | MD | Medical Art Specialist/Technologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Garnet Tattoo | Art, Medical | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1452038400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1751500800000",
"number": "1104282177",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1968 GARNET AVE",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921093555",
"telephone_number": "619-942-9737"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1968 GARNET AVE",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921093555",
"telephone_number": "612-214-1325"
}
],
"practiceLocations": [
{
"address_1": "3073 Jefferson St",
"address_purpose": "LOCATION",
"city": "Napa",
"state": "CA",
"postal_code": "945584921",
"country_code": "US",
"telephone_number": "619-942-9737",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "4933 34th Ave S",
"address_purpose": "LOCATION",
"city": "Minneapolis",
"state": "MN",
"postal_code": "554171503",
"country_code": "US",
"telephone_number": "619-942-9737",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "WALLIN",
"first_name": "SHANE",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-01-06",
"last_updated": "2025-07-03",
"certification_date": "2025-07-03",
"status": "A"
},
"taxonomies": [
{
"code": "246ZA2600X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Other, Art, Medical",
"state": "MN",
"license": "310143",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.