Provider Demographics
NPI:1508384371
Name:EGRESI, SHANE ROBERT (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ROBERT
Last Name:EGRESI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Other - Last Name:
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Mailing Address - Street 1:2304 MEADOW VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-4923
Mailing Address - Country:US
Mailing Address - Phone:330-429-2289
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:330-429-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical