Provider Demographics
NPI:1497838825
Name:SHEA, HOLLY (PA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 WEBSTER ST STE 509
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3149
Mailing Address - Country:US
Mailing Address - Phone:510-452-0330
Mailing Address - Fax:
Practice Address - Street 1:3300 WEBSTER ST STE 509
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3149
Practice Address - Country:US
Practice Address - Phone:510-452-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15397363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA153970Medicare ID - Type Unspecified