Provider Demographics
NPI:1629158639
Name:SHIVES, MICHAEL KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:SHIVES
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 1:13 WESTERN MARYLAND PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6474
Mailing Address - Country:US
Mailing Address - Phone:301-665-4575
Mailing Address - Fax:301-665-4576
Practice Address - Street 1:13 WESTERN MARYLAND PKWY STE 104
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:301-665-4575
Practice Address - Fax:301-665-4576
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03466363A00000X, 363AM0700X
PAMA052414363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103146960Medicaid
MD613LMedicare PIN