Provider Demographics
NPI:1881855187
Name:SHEA, KENNETH JAMES III (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:SHEA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9664
Mailing Address - Country:US
Mailing Address - Phone:320-766-2680
Mailing Address - Fax:
Practice Address - Street 1:3540 17TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9664
Practice Address - Country:US
Practice Address - Phone:320-766-2680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN573222084V0102X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology