Provider Demographics
NPI:1730284076
Name:SHANABERGER, SANDRA D (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:SHANABERGER
Suffix:
Gender:F
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 1:4011 LELAND RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2007
Mailing Address - Country:US
Mailing Address - Phone:859-699-9946
Mailing Address - Fax:502-894-9991
Practice Address - Street 1:1009A N DUPONT SQ
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4612
Practice Address - Country:US
Practice Address - Phone:502-894-9950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA432363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY970021516OtherRR MEDICARE PIN
KYCB5773OtherRR MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
KY95001640Medicaid
KY37903705OtherMEDICAID LAB GROUP
KY970021516OtherRR MEDICARE PIN