Provider Demographics
NPI:1336119916
Name:SPEARS, SHANE FOREE (PA-C, CCP)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:FOREE
Last Name:SPEARS
Suffix:
Gender:M
Credentials:PA-C, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1908
Mailing Address - Country:US
Mailing Address - Phone:903-590-5611
Mailing Address - Fax:
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-590-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004751363A00000X, 363AS0400X
TXPA15805363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1060261Medicaid
WA9468232OtherAETNA
WA0225125OtherL&I AND CRIME VICTIMS
WA1425SPOtherREGENCE
WA8494445Medicaid
WAG8868335Medicare PIN