Shane Kelleher, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA105592 Issued in TX

Practice address

1500 Cooper St
Fort Worth, TX 76104-2710

Phone

(682) 885-7840

Fax

(682) 885-7856

NPI assigned

Jan 22, 2016

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

Flagged The directory lists this NPI on an HHS exclusion list. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Infinit Men'S Health Clinic - Fort Worth

  • Clinic/Center
  • Fort Worth, TX
  • NPI 1386338127
  NPD Authorized official
• Infinit Men'S Health Clinic

  • Physician Assistant
  • Burleson, TX
  • NPI 1871158162
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1453420800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1470096000000",
    "number": "1003273939",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 99371",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761990371",
            "telephone_number": "682-885-1855",
            "fax_number": "682-885-7347"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 COOPER ST",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761042710",
            "telephone_number": "682-885-7840",
            "fax_number": "682-885-7856"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KELLEHER",
        "first_name": "SHANE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-01-22",
        "last_updated": "2016-08-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OK",
            "license": "2628",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": "PA105592",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ann Keith
• Joshua Keithley, M.D.
• Josephine T Kelebeng
• Howard M Kelfer, MD
• Theresa Kellam, PSYCHOLOGIST
• Steven L. Kellenberger, DC
• Keller Crossing Dentistry PLLC
• Keller Desai Dental PLLC
• Keller Modern Dentistry and Orthodontics, PC
• Keller Vision Corporation

• Physician Assistant in Fort Worth, TX
• Providers in Fort Worth, TX by specialty
• Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.