Provider Demographics
NPI:1629359070
Name:BERTSCHE, SHANNON A (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:A
Last Name:BERTSCHE
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 N FINE AVE, SUITE 116
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727
Mailing Address - Country:US
Mailing Address - Phone:402-202-5605
Mailing Address - Fax:
Practice Address - Street 1:1945 N FINE AVE STE 116
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1528
Practice Address - Country:US
Practice Address - Phone:402-489-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22926363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant