Provider Demographics
NPI:1609902063
Name:HIETPAS, SHAY C (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHAY
Middle Name:C
Last Name:HIETPAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:324 WESTON OAKS CT
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2953
Mailing Address - Country:US
Mailing Address - Phone:314-221-6869
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5646
Practice Address - Fax:314-268-6438
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.002927363AS0400X
MO2006038714363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical