Provider Demographics
NPI:1205881349
Name:SHAMROCK-KMECZ, CHRISTANA (PA)
Entity type:Individual
Prefix:
First Name:CHRISTANA
Middle Name:
Last Name:SHAMROCK-KMECZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTANA
Other - Middle Name:
Other - Last Name:KMECZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 MAIN ST STE D1
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2136
Mailing Address - Country:US
Mailing Address - Phone:732-571-1000
Mailing Address - Fax:732-571-1156
Practice Address - Street 1:23 MAIN ST STE D1
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-2136
Practice Address - Country:US
Practice Address - Phone:732-571-1000
Practice Address - Fax:732-571-1156
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00046400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086008Medicare ID - Type Unspecified
P08673Medicare UPIN