Provider Demographics
NPI:1457330425
Name:SHAPIRO, RICKY D (PA C)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:D
Last Name:SHAPIRO
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:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:9301 GOLF RD STE 301
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-7900
Practice Address - Country:US
Practice Address - Phone:847-635-7300
Practice Address - Fax:847-635-7556
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002100363A00000X
IL085.002100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL7073002OtherMEDICARE PTAN
IL085002100Medicaid
ILIL7072002OtherMEDICARE PTAN