Provider Demographics
NPI:1528762879
Name:HARRIS, SHANE STEPHEN (PA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:STEPHEN
Last Name:HARRIS
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 1:1860 W WINCHESTER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5312
Mailing Address - Country:US
Mailing Address - Phone:847-816-6335
Mailing Address - Fax:
Practice Address - Street 1:1860 W WINCHESTER RD STE 106
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5312
Practice Address - Country:US
Practice Address - Phone:847-816-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.009911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant