Healthcare Provider Details

I. General information

NPI: 1689031338
Provider Name (Legal Business Name): KEVIN D SHIELDS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 VENTURE DR
MOUNT VERNON OH
43050-8928
US

IV. Provider business mailing address

1661 VENTURE DR
MOUNT VERNON OH
43050-8928
US

V. Phone/Fax

Practice location:
  • Phone: 740-393-9766
  • Fax: 740-390-6361
Mailing address:
  • Phone: 740-393-9766
  • Fax: 740-390-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004569RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: