Healthcare Provider Details

I. General information

NPI: 1912983990
Provider Name (Legal Business Name): STEVEN TROY SHEARER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 10/28/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4622 COUNTRY CLUB RD SUITE 180
WINSTON-SALEM NC
27104-3770
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-9535
  • Fax: 336-768-4155
Mailing address:
  • Phone: 704-384-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number103495
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103495
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: