Provider Demographics
NPI:1013375351
Name:SHEA, MELANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:KACZINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:614 HUNTERS RUN
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5800
Mailing Address - Country:US
Mailing Address - Phone:419-320-2391
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical