Provider Demographics
NPI:1144256983
Name:GRACIANO, SHAWN LOUISE (PA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:LOUISE
Last Name:GRACIANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:LOUISE
Other - Last Name:DAVISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10629 GOTHIC AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6827
Mailing Address - Country:US
Mailing Address - Phone:818-929-1715
Mailing Address - Fax:
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-2344
Practice Address - Fax:818-502-4501
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15515Medicaid
CAPA15515Medicaid
CAWPA15515BMedicare PIN
CAQ24128Medicare UPIN
CAWPA15515DMedicare PIN