Provider Demographics
NPI:1841804754
Name:SHEA, BRIANNE PUALANI (PA)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:PUALANI
Last Name:SHEA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 MONTGOMERY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4802
Mailing Address - Country:US
Mailing Address - Phone:707-890-4250
Mailing Address - Fax:
Practice Address - Street 1:1162 MONTGOMERY DR STE 300
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4802
Practice Address - Country:US
Practice Address - Phone:707-890-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA60640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program