Provider Demographics
NPI:1003509100
Name:ANDERSON, SHANE MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12923 LAKESHORE N
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-8134
Mailing Address - Country:US
Mailing Address - Phone:530-401-0234
Mailing Address - Fax:
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0925
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6185
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program