Provider Demographics
NPI:1609875632
Name:SASSAMAN, SHELLEY S (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:S
Last Name:SASSAMAN
Suffix:
Gender:F
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:PO BOX 1347
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0347
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:241 CLAREMONT AVENUE
Practice Address - Street 2:
Practice Address - City:HOMETOWN
Practice Address - State:PA
Practice Address - Zip Code:18252-4433
Practice Address - Country:US
Practice Address - Phone:570-225-7211
Practice Address - Fax:570-225-7221
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001448L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S32832Medicare UPIN
PAS32832Medicare UPIN
PA089621LPSMedicare ID - Type Unspecified