Provider Demographics
NPI:1609277201
Name:WRISTON, SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WRISTON
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 1:797 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:IVYDALE
Mailing Address - State:WV
Mailing Address - Zip Code:25113-8263
Mailing Address - Country:US
Mailing Address - Phone:304-286-4200
Mailing Address - Fax:304-286-2107
Practice Address - Street 1:797 CLINIC DR
Practice Address - Street 2:
Practice Address - City:IVYDALE
Practice Address - State:WV
Practice Address - Zip Code:25113-8263
Practice Address - Country:US
Practice Address - Phone:304-286-4200
Practice Address - Fax:304-286-2107
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01845363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical