Provider Demographics
NPI:1730132408
Name:SHANER, TIMOTHY RICHARD (PAC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:SHANER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:4132 WOODLANDS PKWY
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3494
Practice Address - Country:US
Practice Address - Phone:727-786-5100
Practice Address - Fax:727-789-8344
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4042ZMedicare PIN
R55361Medicare UPIN