Physician Compare National (NPI:1528573490)

HEALTHCARE PROVIDER: KELLY RENEE SHANK CRNP

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

Individual Professional Information
NPI	1528573490
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	8022363001
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20180614002253
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	SHANK
	Individual professional last name
Provider First Name	KELLY
	Individual professional first name
Provider Middle Name	RENEE
	Individual professional middle name
Provider Gender	F
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2017
	Individual professional's medical school graduation year
Primary Specialty	NURSE PRACTITIONER
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	GOLLA CENTER FOR PLASTIC SURGERY, P.C.
	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	7618000126
	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	17
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	102 TECHNOLOGY DR
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 210
	Group Practice or individual's line 2 address
City	BUTLER
	Group Practice or individual's city
State	PA
	Group Practice or individual's state
Zip Code	160011784
	Group Practice or individual's zip code (9 digits when available)
Phone Number	7244820191
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	390168
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	BUTLER MEMORIAL HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y