Basic Information
| Provider Information | |||||||||
| NPI: | 1174154256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIPLEY | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 SARNO RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212416800 | ||||||||
| FaxNumber: | 3212416888 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 SARNO RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212416800 | ||||||||
| FaxNumber: | 3212416888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2020 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9112971 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1171095 | 01 | NCCPA | OTHER | PENDING | 05 | FL | MEDICAID | 2PV1U | 01 | FL | BCBS FL | OTHER | 9112971 | 01 | FL | FLORIDA BOARD OF MEDICINE | OTHER |