Provider Demographics
NPI:1659456556
Name:PIERCE, SHANE C (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:C
Last Name:PIERCE
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 1:2401 E STREET NW
Mailing Address - Street 2:M/MED/QI SA-1
Mailing Address - City:WASHINGTON DC
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0102
Mailing Address - Country:US
Mailing Address - Phone:202-663-2453
Mailing Address - Fax:
Practice Address - Street 1:2180 HARARE PL
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20189-2180
Practice Address - Country:US
Practice Address - Phone:202-663-2453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005093363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant