Provider Demographics
NPI:1689001166
Name:MERCHANT, SHANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:MERCHANT
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 1:410 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-2318
Mailing Address - Country:US
Mailing Address - Phone:605-589-2188
Mailing Address - Fax:605-589-4603
Practice Address - Street 1:410 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:TYNDALL
Practice Address - State:SD
Practice Address - Zip Code:57066-2318
Practice Address - Country:US
Practice Address - Phone:605-589-2188
Practice Address - Fax:605-589-4603
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2007146Medicaid