Provider Demographics
NPI:1861452443
Name:BULLER, SHAWN TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:TIMOTHY
Last Name:BULLER
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9332 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3108
Practice Address - Country:US
Practice Address - Phone:704-587-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103765363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2393PAMedicaid
NC1861452443Medicaid
SC2393PAMedicaid
VAVVC173AMedicare PIN
NCNCQ100DMedicare PIN
NCNCQ100EMedicare PIN
NCNCQ100CMedicare PIN
NCNCQ100AMedicare PIN
NCNCQ100BMedicare PIN