Provider Demographics
NPI:1639357676
Name:FUTCHKO, SHANE A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:FUTCHKO
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 1:3930 4TH AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3119
Mailing Address - Country:US
Mailing Address - Phone:352-219-3271
Mailing Address - Fax:
Practice Address - Street 1:3930 4TH AVE
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3119
Practice Address - Country:US
Practice Address - Phone:352-219-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-01
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical