Healthcare Provider Details

I. General information

NPI: 1053084202
Provider Name (Legal Business Name): SHAE MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2021
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5306 NC HIGHWAY 55 SUITE 105
DURHAM NC
27713-7812
US

IV. Provider business mailing address

5306 NC HIGHWAY 55 SUITE 105
DURHAM NC
27713-7812
US

V. Phone/Fax

Practice location:
  • Phone: 919-646-4858
  • Fax: 919-679-7112
Mailing address:
  • Phone: 919-646-4858
  • Fax: 919-679-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY A. MCKINNEY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PA-C
Phone: 919-646-4858