Provider Demographics
NPI:1174869754
Name:VERSCHLEISER, SHIRA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHIRA
Middle Name:
Last Name:VERSCHLEISER
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 1:150 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4101
Mailing Address - Country:US
Mailing Address - Phone:732-363-4003
Mailing Address - Fax:
Practice Address - Street 1:150 JAMES ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4101
Practice Address - Country:US
Practice Address - Phone:732-363-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-30
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00300100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical