Provider Demographics
NPI:1790341311
Name:SHAPAKER, THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SHAPAKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 EXETER RD
Mailing Address - Street 2:STE 250
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3931
Mailing Address - Country:US
Mailing Address - Phone:901-767-5864
Mailing Address - Fax:
Practice Address - Street 1:6025 WALNUT GROVE RD STE 508
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2125
Practice Address - Country:US
Practice Address - Phone:901-570-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3898363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant