Provider Demographics
NPI:1528794138
Name:RAKUSIN, SHELBY (PA-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:RAKUSIN
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 1:6111 VILLA AT THE WOODS
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-4972
Mailing Address - Country:US
Mailing Address - Phone:914-356-6718
Mailing Address - Fax:
Practice Address - Street 1:400 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3417
Practice Address - Country:US
Practice Address - Phone:914-666-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY028690-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant