Provider Demographics
NPI:1992790638
Name:SHEERAN, JEANINE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:MARIE
Last Name:SHEERAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JEANINE
Other - Middle Name:MARIE
Other - Last Name:GEMBALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-2654
Mailing Address - Country:US
Mailing Address - Phone:253-968-1541
Mailing Address - Fax:253-968-2895
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-2654
Practice Address - Country:US
Practice Address - Phone:253-968-1541
Practice Address - Fax:253-968-2895
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001804363AS0400X
IN10000783A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618941OtherBC/BS
IL01618941OtherBC/BS
ILP00326055Medicare PIN
ILP00216826Medicare PIN
IN408430TMedicare PIN
ILP86680Medicare UPIN
ILK14662Medicare PIN