Provider Demographics
NPI:1245361195
Name:SHEA, DUSTIN CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:CHRISTOPHER
Last Name:SHEA
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 1:207 N CIRCULO ROBEL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-2330
Mailing Address - Country:US
Mailing Address - Phone:909-762-9085
Mailing Address - Fax:
Practice Address - Street 1:19066 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2232
Practice Address - Country:US
Practice Address - Phone:714-378-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant