Healthcare Provider Details

I. General information

NPI: 1003936956
Provider Name (Legal Business Name): PAUL E. SHUTTLEWORTH JR. RN, CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 HIGHCREST LN
SOUTH SAN FRANCISCO CA
94080-7303
US

IV. Provider business mailing address

38 HIGHCREST LN
SOUTH SAN FRANCISCO CA
94080-7303
US

V. Phone/Fax

Practice location:
  • Phone: 650-321-9999
  • Fax: 650-615-9995
Mailing address:
  • Phone: 650-321-9999
  • Fax: 650-615-9995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number830077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: