Provider Demographics
NPI:1083812929
Name:LOVLEY, SHANE B (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:B
Last Name:LOVLEY
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 1:80 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:ME
Mailing Address - Zip Code:04553-3838
Mailing Address - Country:US
Mailing Address - Phone:207-563-3366
Mailing Address - Fax:207-563-3393
Practice Address - Street 1:80 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:ME
Practice Address - Zip Code:04553-3838
Practice Address - Country:US
Practice Address - Phone:207-563-3366
Practice Address - Fax:207-563-3393
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432821199Medicaid