Provider Demographics
NPI:1912161589
Name:YOUNG, SHEA KERSH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHEA
Middle Name:KERSH
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:SHEA
Other - Last Name:KERSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 RICHLAND WEST CIR STE 2C
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7935
Mailing Address - Country:US
Mailing Address - Phone:254-340-6000
Mailing Address - Fax:254-340-6010
Practice Address - Street 1:300 RICHLAND WEST CIR STE 2C
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7935
Practice Address - Country:US
Practice Address - Phone:254-340-6000
Practice Address - Fax:254-340-6010
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA128955ETVMedicare PIN