Active NPI
Kenneth Scott Shedarowich, PA-C
- Physician Assistant
- Pinehurst, NC
National Provider Identifier
1134257553
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- Practice address
- 155 Memorial Dr
Pinehurst, NC 28374-8710 - Phone
- (910) 715-2164
- Fax
- (910) 715-1926
- NPI assigned
- Feb 28, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | PA13309 | CA | |
| Physician Assistant | 363A00000X | Primary |
Addresses
Primary practice location
155 Memorial Dr
Pinehurst, NC 28374-8710
Mailing address
PO Box 8500
Pinehurst, NC 28374-8500
Phone (910) 715-2164
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA13309 | CA | MD | Medical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172620800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1433894400000",
"number": "1134257553",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 8500",
"city": "PINEHURST",
"state": "NC",
"postal_code": "283748500",
"telephone_number": "910-715-2164",
"fax_number": "910-715-1926"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "155 MEMORIAL DR",
"city": "PINEHURST",
"state": "NC",
"postal_code": "283748710",
"telephone_number": "910-715-2164",
"fax_number": "910-715-1926"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHEDAROWICH",
"first_name": "KENNETH",
"middle_name": "SCOTT",
"credential": "PA-C",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-02-28",
"last_updated": "2015-06-10",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "CA",
"license": "PA13309",
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pinehurst, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.