Healthcare Provider Details

I. General information

NPI: 1902102676
Provider Name (Legal Business Name): KERRY KATHLEEN SHUFFELBOTTOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BLUE MOON XING STE 203
POOLER GA
31322-9698
US

IV. Provider business mailing address

5191 FIRST COAST TECH PKWY FL 3
JACKSONVILLE FL
32224-0609
US

V. Phone/Fax

Practice location:
  • Phone: 912-590-0973
  • Fax: 912-590-0180
Mailing address:
  • Phone: 904-223-3321
  • Fax: 904-223-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2131
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2131
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: