Provider Demographics
NPI:1295055077
Name:CHUBBUCK, SHEA FETHERSTON (PA-C)
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:FETHERSTON
Last Name:CHUBBUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHEA
Other - Middle Name:ELIZABETH
Other - Last Name:FETHERSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2515 FORESIGHT CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1018
Mailing Address - Country:US
Mailing Address - Phone:970-245-2400
Mailing Address - Fax:970-242-9092
Practice Address - Street 1:2515 FORESIGHT CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1018
Practice Address - Country:US
Practice Address - Phone:970-242-8177
Practice Address - Fax:970-255-3558
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003935363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00657271Medicaid
WI1295055077Medicaid
WI73601 1806Medicare PIN
CO00657271Medicaid