Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Stag Blair Shadduck

Individual provider Physician Assistant · NPI 1962093674

Stag Blair Shadduck is a Physician Assistant in Edgewood, Kentucky. Qualified in 2021, 5 years ago. Practices with Orthocincy Orthopaedics and Sports Medicine PSC, a 164-clinician group and accepts Medicare assignment. Licensed in Kentucky.

Years since qualifying
5
Licensed in
KY
In the registry since
2021
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Practice location Address checks out

560 S Loop Rd
Edgewood, KY 41017-3405
Phone: (859) 301-2663
Fax: (859) 817-7848
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X · Licence TC072 (KY)

Record details

NPI number1962093674
Entity typeIndividual (Type 1)
GenderMale
Sole proprietorYes
NPI enumeratedJanuary 27, 2021
Last updated in NPPESAugust 18, 2021
Certification dateAugust 18, 2021

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2021 (5 years in practice)
Group practice Orthocincy Orthopaedics And Sports Medicine Psc — 164 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations3 on file with Medicare

Other providers in Edgewood