Provider Demographics
NPI:1306836689
Name:SHEA, DANIEL LEO (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEO
Last Name:SHEA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 SUGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-5565
Mailing Address - Country:US
Mailing Address - Phone:828-652-8727
Mailing Address - Fax:828-652-8793
Practice Address - Street 1:1860 SUGAR HILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-5565
Practice Address - Country:US
Practice Address - Phone:828-652-8727
Practice Address - Fax:828-652-8793
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC84847OtherMEDCOST ID #
NCS60462Medicare UPIN
NC2748166Medicare ID - Type UnspecifiedMEDICARE ID #