Provider Demographics
NPI:1114001443
Name:SHULL, BRIAN ROBERT (RPA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:SHULL
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 FURMAN CRES
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2801
Mailing Address - Country:US
Mailing Address - Phone:518-524-4314
Mailing Address - Fax:
Practice Address - Street 1:10 HAGEN DR
Practice Address - Street 2:STE 350
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2660
Practice Address - Country:US
Practice Address - Phone:585-385-5555
Practice Address - Fax:585-385-5611
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007747363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ36989Medicare UPIN