Provider Demographics
NPI:1174816847
Name:FOSTER, SHAUNA ASHLEY (PA)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:ASHLEY
Last Name:FOSTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:ASHLEY
Other - Last Name:MIKEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-1265
Mailing Address - Fax:704-316-1266
Practice Address - Street 1:14330 OAKHILL PARK LANE
Practice Address - Street 2:SUITE 200B
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3407
Practice Address - Country:US
Practice Address - Phone:704-316-1265
Practice Address - Fax:704-316-1266
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02861207RG0100X
NC001002861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology