Provider Demographics
NPI:1356505135
Name:VAN SICKLE, SHASTA ROANN (PA-C)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:ROANN
Last Name:VAN SICKLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:ROANN
Other - Last Name:BEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2801 PURCELL ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-3551
Mailing Address - Country:US
Mailing Address - Phone:303-659-9700
Mailing Address - Fax:303-558-8222
Practice Address - Street 1:660 GOLDEN RIDGE RD
Practice Address - Street 2:STE. 250
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-9541
Practice Address - Country:US
Practice Address - Phone:303-233-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1356505135Medicaid
CO55036724Medicaid
CO55036724Medicaid
COCO306737Medicare PIN