Provider Demographics
NPI:1013640283
Name:JOY, SHANE THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:THOMAS
Last Name:JOY
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 1:48 PINEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:DEEP RIVER
Mailing Address - State:CT
Mailing Address - Zip Code:06417-1609
Mailing Address - Country:US
Mailing Address - Phone:860-526-1320
Mailing Address - Fax:
Practice Address - Street 1:256 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2004
Practice Address - Country:US
Practice Address - Phone:860-696-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant