Provider Demographics
NPI:1336309384
Name:TSUBAKI, SHANE M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:M
Last Name:TSUBAKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:SHANE
Other - Middle Name:M
Other - Last Name:YOSHIMOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:15744 FAIROAKS AVE N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8552
Mailing Address - Country:US
Mailing Address - Phone:541-212-9382
Mailing Address - Fax:
Practice Address - Street 1:11990 BUSINESS PARK BLVD N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant