Basic Information
| Provider Information | |||||||||
| NPI: | 1356934962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 W ALFRED ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336035514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506941289 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 3RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417920340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2021 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9114019 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.