Provider Demographics
NPI:1467857078
Name:SHINN, CHARDONNAY (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARDONNAY
Middle Name:
Last Name:SHINN
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 1:5 JOURNEY
Mailing Address - Street 2:SUITE #130
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5336
Mailing Address - Country:US
Mailing Address - Phone:949-360-1069
Mailing Address - Fax:
Practice Address - Street 1:5 JOURNEY
Practice Address - Street 2:SUITE #130
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5336
Practice Address - Country:US
Practice Address - Phone:949-360-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant