Provider Demographics
NPI:1114589405
Name:EGGLESTON, SHACARA (MPAS, ATC, PA-C)
Entity Type:Individual
Prefix:
First Name:SHACARA
Middle Name:
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:MPAS, ATC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5860 RANCH LAKE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-3719
Mailing Address - Country:US
Mailing Address - Phone:941-388-8997
Mailing Address - Fax:
Practice Address - Street 1:5860 RANCH LAKE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-3719
Practice Address - Country:US
Practice Address - Phone:941-388-8997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116169363A00000X
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1114589405Medicaid