Provider Demographics
NPI:1114322153
Name:THERIAULT, SHAHANA LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAHANA
Middle Name:LEE
Last Name:THERIAULT
Suffix:
Gender:F
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 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:2408 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3209
Practice Address - Country:US
Practice Address - Phone:203-407-3500
Practice Address - Fax:203-407-4244
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114322153Medicaid
CT1114322153Medicaid