Physician Compare National (NPI:1124355359)

HEALTHCARE PROVIDER: SHANE UDELHOVEN PA-C

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1124355359
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	6608905930
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20100525001036
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	UDELHOVEN
	Individual professional last name
Provider First Name	SHANE
	Individual professional first name
Provider Middle Name	M
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2009
	Individual professional's medical school graduation year
Primary Specialty	PHYSICIAN ASSISTANT
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	RIVER HEALTH AND WELLNESS, LLC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	2163754540
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	3
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	35670 KENAI SPUR HWY
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 103A
	Group Practice or individual's line 2 address
City	SOLDOTNA
	Group Practice or individual's city
State	AK
	Group Practice or individual's state
Zip Code	996697649
	Group Practice or individual's zip code (9 digits when available)
Phone Number	9072601655
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Professional Accepts Medicare Assignment	Y