Provider Demographics
NPI:1487207213
Name:MCNICHOL, SHAWN (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:MCNICHOL
Suffix:
Gender:M
Credentials:PA
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 100183
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0183
Mailing Address - Country:US
Mailing Address - Phone:352-392-0140
Mailing Address - Fax:352-392-8217
Practice Address - Street 1:600 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5925
Practice Address - Country:US
Practice Address - Phone:352-323-2337
Practice Address - Fax:352-392-8217
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9112703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105590600Medicaid