Provider Demographics
NPI:1225007347
Name:SHAVER, JEANNELLE M (RPA)
Entity Type:Individual
Prefix:
First Name:JEANNELLE
Middle Name:M
Last Name:SHAVER
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MYRTLE AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3797
Mailing Address - Country:US
Mailing Address - Phone:518-262-5640
Mailing Address - Fax:518-262-5110
Practice Address - Street 1:102 PARK STREET PRYUN PAVILIOIN AT GLENS FALLS HOSPITAL
Practice Address - Street 2:THE VASCULAR GROUP PLLC
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-792-7122
Practice Address - Fax:518-792-3800
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02341202Medicaid
NY02341202Medicaid
PA0145Medicare ID - Type Unspecified