Provider Demographics
NPI:1215596317
Name:DANIELS, SHADOE M (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:SHADOE
Middle Name:M
Last Name:DANIELS
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8881 NY-97
Mailing Address - Street 2:
Mailing Address - City:CALLICOON
Mailing Address - State:NY
Mailing Address - Zip Code:12723
Mailing Address - Country:US
Mailing Address - Phone:845-333-6800
Mailing Address - Fax:
Practice Address - Street 1:8881 NY-97
Practice Address - Street 2:
Practice Address - City:CALLICOON
Practice Address - State:NY
Practice Address - Zip Code:12723
Practice Address - Country:US
Practice Address - Phone:845-333-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060726363AM0700X
NY024896363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical