Provider Demographics
NPI:1396340204
Name:SHEA, KATHRYN FITZPATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:FITZPATRICK
Last Name:SHEA
Suffix:
Gender:F
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 1:745 SPRINGROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-2172
Mailing Address - Country:US
Mailing Address - Phone:770-296-9279
Mailing Address - Fax:
Practice Address - Street 1:2383 PATE ST N
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3250
Practice Address - Country:US
Practice Address - Phone:770-972-4845
Practice Address - Fax:770-972-0358
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant