Provider Demographics
NPI:1073580973
Name:SHEA, DAWN MARIE (PA)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PARK DR
Practice Address - Street 2:STE 210
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2948
Practice Address - Country:US
Practice Address - Phone:704-403-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1034PAMedicaid
NC1073580973Medicaid
SC1034PAMedicaid
NC2755519AMedicare UPIN
NC1073580973Medicaid