Provider Demographics
NPI:1578177572
Name:WILKINS, SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WILKINS
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 1:1910 HALSEY LN
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NY
Mailing Address - Zip Code:14860-9607
Mailing Address - Country:US
Mailing Address - Phone:607-582-7404
Mailing Address - Fax:
Practice Address - Street 1:800 2ND AVE FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4709
Practice Address - Country:US
Practice Address - Phone:212-991-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant