Provider Demographics
NPI:1568938280
Name:DOTY, SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:DOTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 N MCCLINTOCK DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3711
Mailing Address - Country:US
Mailing Address - Phone:480-464-4431
Mailing Address - Fax:480-464-2338
Practice Address - Street 1:70 N MCCLINTOCK DR STE 4
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3711
Practice Address - Country:US
Practice Address - Phone:480-464-4431
Practice Address - Fax:480-464-2338
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ7549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty