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General NPI Number Information
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NPI Number | 1669178075
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Entity Type | Individual
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Provider Name | SHANE WILBURN PA-C
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Gender | Male
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Dates
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Enumeration Date | 02/07/2023
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 89 OLD TROLLEY RD STE 102
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City | SUMMERVILLE
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State | SC
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Zip | 29485-4951
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Country | US
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Telephone | 854-206-5513
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Fax | 854-246-8965
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Provider Business Mailing Address
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Address Line | 111 ROWBOAT RD
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City | SUMMERVILLE
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State | SC
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Zip | 29486-6900
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Country | US
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Telephone | 419-689-2923
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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