Provider Demographics
NPI:1649448572
Name:WALKER, SHANE D (PA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:D
Last Name:WALKER
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 1:55 MAUI LANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2416
Mailing Address - Country:US
Mailing Address - Phone:808-243-6050
Mailing Address - Fax:
Practice Address - Street 1:55 MAUI LANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-243-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005374363A00000X
HIAMD-913363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8505448Medicaid
WA231200OtherLABOR & INDUST
WAPA10005374OtherLICENSE
WA8871003Medicare PIN