Provider Demographics
NPI:1356442198
Name:SHEA, GREGORY F (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:F
Last Name:SHEA
Suffix:
Gender:M
Credentials:PA
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 NE GATEWAY CT NE
Practice Address - Street 2:STE 204
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2414
Practice Address - Country:US
Practice Address - Phone:704-403-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103368363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2342616OtherMEDICARE PTAN, GROUP
NC8935521Medicaid
NCNC5778AMedicare PIN
NCP57845Medicare UPIN
NC2755371AMedicare ID - Type Unspecified