Provider Demographics
NPI:1962482877
Name:TIPTON, SHANE ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ANDREW
Last Name:TIPTON
Suffix:
Gender:M
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 1:1000 GREENLEY RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5200
Mailing Address - Country:US
Mailing Address - Phone:209-536-5000
Mailing Address - Fax:
Practice Address - Street 1:1000 GREENLEY RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5200
Practice Address - Country:US
Practice Address - Phone:209-536-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17521364SE0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA175210Medicaid
CAOPA175210Medicaid
Q25289Medicare UPIN