Provider Demographics
NPI:1548397243
Name:SHEA, STACIA N (PA)
Entity Type:Individual
Prefix:MS
First Name:STACIA
Middle Name:N
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 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:678-288-9555
Mailing Address - Fax:678-288-9556
Practice Address - Street 1:1100 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 600
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-256-4777
Practice Address - Fax:404-256-5515
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA558666655IMedicaid
GA558666655IMedicaid