Provider Demographics
NPI:1437142213
Name:MORGAN, SHANE C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:C
Last Name:MORGAN
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 1:3 WAKE ROBIN RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4208
Mailing Address - Country:US
Mailing Address - Phone:401-475-9140
Mailing Address - Fax:401-475-2808
Practice Address - Street 1:3 WAKE ROBIN RD UNIT 5
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4208
Practice Address - Country:US
Practice Address - Phone:401-475-9140
Practice Address - Fax:401-475-2808
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00266363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI201049483OtherUNITED HEALTH
RI409375OtherBLUE CHIP
RI0000030809OtherBC BS OF RHODE ISALND
RI9004028Medicaid
RI201049483OtherCOMMERCIAL