Provider Demographics
NPI:1306866918
Name:BERTIN, SHANA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:MARIE
Last Name:BERTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SHANA
Other - Middle Name:MARIE
Other - Last Name:RUHNKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306866918Medicaid
NH30337108Medicaid
WI1306866918Medicaid
NH30337108Medicaid