Provider Demographics
NPI:1225015795
Name:KINSEY, SHANE P (PAC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:P
Last Name:KINSEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:HARTFORD MEDICAL GROUP
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1086
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:1260 SILAS DEANE HIGHWAY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109
Practice Address - Country:US
Practice Address - Phone:860-529-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001450363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970002008Medicare PIN
Q04676Medicare UPIN