Healthcare Provider Details

I. General information

NPI: 1679091920
Provider Name (Legal Business Name): SHANE JOSEPH EWALT PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S CHANDLER VILLAGE DR
CHANDLER AZ
85226-5069
US

IV. Provider business mailing address

PO BOX 80217
PHOENIX AZ
85060-0217
US

V. Phone/Fax

Practice location:
  • Phone: 480-750-0303
  • Fax: 480-786-5202
Mailing address:
  • Phone: 602-385-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6865
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6865
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: