Provider Demographics
NPI:1477095545
Name:OGLE, SHONETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHONETTE
Middle Name:
Last Name:OGLE
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 1:301 E 99TH ST
Mailing Address - Street 2:514
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-7469
Mailing Address - Country:US
Mailing Address - Phone:347-923-1353
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-904-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant