MEDICARE: SHANA YALA WABIBI PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-15161	NC

General Provider Information

NPI Number	:	1891503249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA YALA WABIBI PA-C

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	151A RUTLEDGE AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-8903
Country	:	US
Telephone Number	:	704-807-2601
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2024
Last Update Date	:	12/29/2025

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