Provider Demographics
NPI:1366557472
Name:SHUTAK, MICHAEL II (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:SHUTAK
Suffix:II
Gender:M
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 1:2601 N HERRITAGE ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1502
Mailing Address - Country:US
Mailing Address - Phone:252-208-7800
Mailing Address - Fax:
Practice Address - Street 1:2601 N HERRITAGE ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1502
Practice Address - Country:US
Practice Address - Phone:252-208-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12410017OtherCAQH