Provider Demographics
NPI:1033588405
Name:SHAPAKA, ALYSE (PA)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:SHAPAKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALYSE
Other - Middle Name:
Other - Last Name:MCNEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:740-434-0565
Practice Address - Fax:740-434-0563
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0144540Medicaid
OH0144540Medicaid
OHH448760Medicare PIN