Provider Demographics
NPI:1508532755
Name:SHIELDS, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:WISKUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-4100
Mailing Address - Country:US
Mailing Address - Phone:716-667-2294
Mailing Address - Fax:
Practice Address - Street 1:40 CENTRE DR
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-4100
Practice Address - Country:US
Practice Address - Phone:716-667-2294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5108784174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist