Provider Demographics
NPI:1396425427
Name:MCNAMARA GAZZO, SHANE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MCNAMARA GAZZO
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 1:100 BULLOCKS POINT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5351
Mailing Address - Country:US
Mailing Address - Phone:401-437-1008
Mailing Address - Fax:401-433-3042
Practice Address - Street 1:2 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:RI
Practice Address - Zip Code:02806-1600
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant