Provider Demographics
NPI:1912954900
Name:SHEA, MAUREEN A (PA)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:A
Last Name:SHEA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4617
Mailing Address - Country:US
Mailing Address - Phone:716-204-4500
Mailing Address - Fax:716-204-4501
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2648
Practice Address - Country:US
Practice Address - Phone:716-204-4500
Practice Address - Fax:716-204-4501
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005534-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02354272Medicaid
NYCC0395Medicare PIN