Healthcare Provider Details

I. General information

NPI: 1194875807
Provider Name (Legal Business Name): MICHAEL A. SHEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 E BIDWELL ST STE 160
FOLSOM CA
95630-6446
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-817-3730
  • Fax: 916-817-3731
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA79231
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA79231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: