Provider Demographics
NPI:1417977562
Name:STANDARD, SHANA S (PA)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:S
Last Name:STANDARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E. 65TH STREET
Mailing Address - Street 2:SUITE 22
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-3320
Practice Address - Street 1:836 E. 65TH STREET
Practice Address - Street 2:SUITE 9
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-819-5090
Practice Address - Fax:912-819-0591
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000855CMedicaid
GAP00610133OtherRR MEDICARE
01270783OtherAMERIGROUP
GA511I970367Medicare PIN
01270783OtherAMERIGROUP