Provider Demographics
NPI:1174914857
Name:CAMPBELL, SHAWN ROBERT (PA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:ROBERT
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1491 SHERIDAN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1234
Mailing Address - Country:US
Mailing Address - Phone:716-332-4476
Mailing Address - Fax:716-332-4479
Practice Address - Street 1:1491 SHERIDAN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14217-1234
Practice Address - Country:US
Practice Address - Phone:716-332-4476
Practice Address - Fax:716-332-4479
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY23 018431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant