Provider Demographics
NPI:1447280508
Name:ANGLETON, M SHANE (PA)
Entity type:Individual
Prefix:
First Name:M
Middle Name:SHANE
Last Name:ANGLETON
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 1:9562 STATE ROUTE #13
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13316-4940
Mailing Address - Country:US
Mailing Address - Phone:315-245-5029
Mailing Address - Fax:315-245-5056
Practice Address - Street 1:9562 STATE ROUTE #13
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-4940
Practice Address - Country:US
Practice Address - Phone:315-245-5029
Practice Address - Fax:315-245-5056
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003097-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC3193Medicare ID - Type Unspecified
NYS28493Medicare UPIN