Shane Park, MS, RD

Primary specialty

Registered DietitianTaxonomy code 133V00000X

Practice address

27 Forestdale Rd
Kinnelon, NJ 07405-2558

Phone

(973) 879-6811

NPI assigned

Jul 5, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1625443200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1625443200000",
    "number": "1528639283",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "27 FORESTDALE RD",
            "city": "KINNELON",
            "state": "NJ",
            "postal_code": "074052558"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "27 FORESTDALE RD",
            "city": "KINNELON",
            "state": "NJ",
            "postal_code": "074052558",
            "telephone_number": "973-879-6811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "SHANE",
        "credential": "MS, RD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-07-05",
        "last_updated": "2021-07-05",
        "certification_date": "2021-07-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Registered Dietitian in Kinnelon, NJ
• Providers in Kinnelon, NJ by specialty
• Registered Dietitian in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 5, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.