Provider Demographics
NPI:1467843011
Name:SHIELDS, KARISSA V (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:V
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2510 W HORIZON RIDGE PKWY
Mailing Address - Street 2:130
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-1601
Mailing Address - Country:US
Mailing Address - Phone:702-263-7800
Mailing Address - Fax:702-263-0087
Practice Address - Street 1:2510 W HORIZON RIDGE PKWY
Practice Address - Street 2:130
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-1601
Practice Address - Country:US
Practice Address - Phone:702-263-7800
Practice Address - Fax:702-263-0087
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504311Medicaid