Provider Demographics
NPI:1871533240
Name:SHAVALIER, ALISSA JAN (PAC)
Entity type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:JAN
Last Name:SHAVALIER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:JAN
Other - Last Name:LAGRASTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1112 GOODLETTE RD N STE 204
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5499
Mailing Address - Country:US
Mailing Address - Phone:239-262-4519
Mailing Address - Fax:239-262-5672
Practice Address - Street 1:1112 GOODLETTE RD N STE 204
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5499
Practice Address - Country:US
Practice Address - Phone:239-262-4519
Practice Address - Fax:239-262-5672
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00397448OtherRAILROAD MEDICARE
FLAC864ZMedicare PIN
FLP00397448OtherRAILROAD MEDICARE