Provider Demographics
NPI:1063643856
Name:SHIPLEY, JACOB WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WAYNE
Last Name:SHIPLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 S PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2262
Mailing Address - Country:US
Mailing Address - Phone:814-445-3575
Mailing Address - Fax:814-445-5700
Practice Address - Street 1:126 E CHURCH ST STE 2400
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501
Practice Address - Country:US
Practice Address - Phone:814-443-5800
Practice Address - Fax:814-443-5499
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD450197207L00000X, 208VP0000X
OH35.123054207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH318750OtherMEDICARE PTAN
PACI6140OtherRAILROAD MEDICARE
OH618271100OtherACS DEPT OF LABOR WC
PA0015083500031Medicaid
PA002533543OtherHIGHMARK BLUE SHIELD
OH000000873681OtherANTHEM BCBS
OH12700751OtherCAQH
PA710929OtherMEDICARE