Healthcare Provider Details

I. General information

NPI: 1265766422
Provider Name (Legal Business Name): SHEA PERILLO P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6553 E BAYWOOD AVE
MESA AZ
85206-1752
US

IV. Provider business mailing address

6553 E BAYWOOD AVE STE 101B
MESA AZ
85206-1752
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-3532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4507
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4507
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: