Provider Demographics
NPI:1740673243
Name:SHADLE, KIRSTEN ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ELIZABETH
Last Name:SHADLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:ELIZABETH
Other - Last Name:WETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2050
Practice Address - Country:US
Practice Address - Phone:570-214-7967
Practice Address - Fax:570-214-2800
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003496363A00000X, 363AM0700X
PAMA058015363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical