Provider Demographics
NPI:1457377616
Name:BOLLINGER, SHAWN A (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:A
Last Name:BOLLINGER
Suffix:
Gender:M
Credentials:PA
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:225 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3050
Practice Address - Country:US
Practice Address - Phone:864-560-4420
Practice Address - Fax:864-560-5296
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000462A363AS0400X
SC2363363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2241PAMedicaid
970018928OtherRAILROAD MEDICARE PIN
000000375781OtherBCBS PIN
000000375781OtherBCBS PIN
IN558430033Medicare PIN
970018928OtherRAILROAD MEDICARE PIN
SCSC62475019Medicare PIN