Provider Demographics
NPI:1710988100
Name:ORTEGA, SHAUN MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:MICHAEL
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7580 NORTHCLIFF AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3270
Mailing Address - Country:US
Mailing Address - Phone:216-472-2741
Mailing Address - Fax:216-472-2739
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-369-2800
Practice Address - Fax:216-369-0456
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-10-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH50001422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0069895Medicaid
OHP11766Medicare UPIN
OH0069895Medicaid