Provider Demographics
NPI:1336186550
Name:COLE, SHAUNA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:COLE
Suffix:
Gender:F
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 1:120 ERIE CANAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4609
Mailing Address - Country:US
Mailing Address - Phone:585-719-9600
Mailing Address - Fax:
Practice Address - Street 1:120 ERIE CANAL DR STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4609
Practice Address - Country:US
Practice Address - Phone:585-719-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA-980363AM0700X
NY021964-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100511202Medicaid
NY1336186550Medicaid