Provider Demographics
NPI:1316922396
Name:HIGGINS, SHANE M (PA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:HIGGINS
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 1:640 S 19TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-2902
Mailing Address - Country:US
Mailing Address - Phone:515-382-5413
Mailing Address - Fax:515-382-7107
Practice Address - Street 1:640 S 19TH ST STE 100
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:IA
Practice Address - Zip Code:50201
Practice Address - Country:US
Practice Address - Phone:515-382-5413
Practice Address - Fax:515-382-7107
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00709212OtherRR MEDICARE
DA1548OtherRR MEDICARE GROUP
P00709212OtherRR MEDICARE