MEDICARE: MR. SHANE WILLIAM ROBACK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9121269	FL

General Provider Information

NPI Number	:	1760331524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE WILLIAM ROBACK PA-C

Provider Business Mailing Address
First Line	:	19920 BRIDGETOWN LOOP
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34293-2281
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1540 S TAMIAMI TRL STE 401
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34239-2921
Country	:	US
Telephone Number	:	941-917-0060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2026
Last Update Date	:	04/20/2026

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