Provider Demographics
NPI:1922350073
Name:O'NEIL, SHANE R (PA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:R
Last Name:O'NEIL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3340 ROBINWOOD RD STE 100-534
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-6689
Mailing Address - Country:US
Mailing Address - Phone:980-233-3234
Mailing Address - Fax:
Practice Address - Street 1:14330 OAKHILL PARK LN STE 135
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3409
Practice Address - Country:US
Practice Address - Phone:704-544-7832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2023-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400080692Medicare PIN