Provider Demographics
NPI:1124167457
Name:WAUGH, SHAWN (PA -L)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:WAUGH
Suffix:
Gender:M
Credentials:PA -L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 NW AMERICAN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4828
Mailing Address - Country:US
Mailing Address - Phone:386-758-6094
Mailing Address - Fax:386-758-6995
Practice Address - Street 1:4355 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4828
Practice Address - Country:US
Practice Address - Phone:386-758-6094
Practice Address - Fax:386-758-6995
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103422363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ66427Medicare UPIN
FLU7165ZMedicare ID - Type Unspecified