Provider Demographics
NPI:1609248046
Name:DUDA, SHANE HENRY (PA-C)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:HENRY
Last Name:DUDA
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 1:627 EASTLAND AVE SE STE 102
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4501
Mailing Address - Country:US
Mailing Address - Phone:330-306-5030
Mailing Address - Fax:
Practice Address - Street 1:627 EASTLAND AVE SE STE 102
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4501
Practice Address - Country:US
Practice Address - Phone:330-306-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057965363AM0700X
OH50.004537363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical