Provider Demographics
NPI:1437707031
Name:BELTZ, SHAWN THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:THOMAS
Last Name:BELTZ
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 1:13083 FREDERICKTOWN AMITY RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-9602
Mailing Address - Country:US
Mailing Address - Phone:419-560-8962
Mailing Address - Fax:
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:419-560-8962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0373693Medicaid