Provider Demographics
NPI:1982712394
Name:WEEDON, SHELLY L (PA-C)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:WEEDON
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 1:288 GROVE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3934
Mailing Address - Country:US
Mailing Address - Phone:508-552-3130
Mailing Address - Fax:978-371-0522
Practice Address - Street 1:288 GROVE ST STE 201
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3934
Practice Address - Country:US
Practice Address - Phone:508-552-3130
Practice Address - Fax:978-371-0522
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1380Medicare ID - Type Unspecified
P21598Medicare UPIN
MAAP138002Medicare PIN