Provider Demographics
NPI:1902102676
Name:SHUFFELBOTTOM, KERRY KATHLEEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:KATHLEEN
Last Name:SHUFFELBOTTOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0609
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:200 BLUE MOON XING STE 203
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9698
Practice Address - Country:US
Practice Address - Phone:912-590-0973
Practice Address - Fax:912-590-0180
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2131363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY06PSOtherBCBS
FL0032613-00Medicaid
FL0032613-00Medicaid
FL1290460001Medicare NSC