Provider Demographics
NPI:1821587510
Name:SHANK, KRISTINA (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SHANK
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 1:11804 HARBOUR LIGHT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-2609
Mailing Address - Country:US
Mailing Address - Phone:440-667-8765
Mailing Address - Fax:
Practice Address - Street 1:3999 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6046
Practice Address - Country:US
Practice Address - Phone:216-285-4195
Practice Address - Fax:216-201-7110
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005478RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant