Provider Demographics
NPI:1033386420
Name:SHANLEY, PATRICK KEENAN (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:KEENAN
Last Name:SHANLEY
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 1:1397 WEIMER RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6253
Mailing Address - Country:US
Mailing Address - Phone:505-758-0009
Mailing Address - Fax:505-758-8736
Practice Address - Street 1:1219 GUSDORF RD STE A
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6499
Practice Address - Country:US
Practice Address - Phone:505-758-0009
Practice Address - Fax:505-758-8736
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2008-0045363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical