Healthcare Provider Details

I. General information

NPI: 1750856647
Provider Name (Legal Business Name): JOHN O'SHEA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E OAK AVE
FLAGSTAFF AZ
86001-1818
US

IV. Provider business mailing address

575 TURNPIKE ST STE 21
NORTH ANDOVER MA
01845-5937
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-7880
  • Fax:
Mailing address:
  • Phone: 978-794-1946
  • Fax: 978-975-3925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10516
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0031458
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: