Provider Demographics
NPI:1629809736
Name:SHEA, CAROLINE MARY
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MARY
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8931 SCENIC CRK
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1682
Mailing Address - Country:US
Mailing Address - Phone:303-514-8331
Mailing Address - Fax:
Practice Address - Street 1:502 MADISON OAK DR STE 310
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4298
Practice Address - Country:US
Practice Address - Phone:210-483-8883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1171095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty