Provider Demographics
NPI:1154561884
Name:SHAKUN, LISA E (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:SHAKUN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OLD ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1711
Mailing Address - Country:US
Mailing Address - Phone:860-650-3848
Mailing Address - Fax:
Practice Address - Street 1:370 MIDDLE TPKE W
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3824
Practice Address - Country:US
Practice Address - Phone:860-650-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013444363A00000X
MAPA7540363A00000X
CT002236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400002850Medicare PIN