Provider Demographics
NPI:1457330532
Name:MCBRIDE, SHAUNA L (PA C)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:L
Last Name:MCBRIDE
Suffix:
Gender:F
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 1:168 N 100 E
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2893
Mailing Address - Country:US
Mailing Address - Phone:435-986-2565
Mailing Address - Fax:435-986-2577
Practice Address - Street 1:168 N 100 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2893
Practice Address - Country:US
Practice Address - Phone:435-986-2565
Practice Address - Fax:435-986-2577
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT58509011206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT352163112003Medicaid
UT461819OtherMEDICARE UGS
352163112017OtherMEDICAID PCN
000057177OtherMEDICARE B
UT352163112003Medicaid