Provider Demographics
NPI:1114786795
Name:BOOKER, SHATAESIA S (PA)
Entity Type:Individual
Prefix:
First Name:SHATAESIA
Middle Name:S
Last Name:BOOKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 ECCLES LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-9580
Mailing Address - Country:US
Mailing Address - Phone:864-380-2819
Mailing Address - Fax:
Practice Address - Street 1:3758 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-1959
Practice Address - Country:US
Practice Address - Phone:910-429-0647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant