Provider Demographics
NPI:1356556724
Name:GIDDENS, SHANE LEON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:LEON
Last Name:GIDDENS
Suffix:
Gender:M
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:1211 SHERWOOD PARK DR NE STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-219-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005490363A00000X, 363AS0400X
FLPA9103541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003101100AMedicaid
GA576107OtherWELLCARE
GAP00903093OtherRAILROAD MEDICARE
SC1278PAMedicaid
FL293016100Medicaid
GAP00903093OtherRAILROAD MEDICARE
FL293016100Medicaid
FL3894080001Medicare NSC