Provider Demographics
NPI:1033194931
Name:WHITAKER, SHANNON MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401
Mailing Address - Country:US
Mailing Address - Phone:910-341-1886
Mailing Address - Fax:910-343-6019
Practice Address - Street 1:1025 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-341-1886
Practice Address - Fax:910-343-6019
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2743473COtherMEDICARE
NC7901897Medicaid
NC970010711OtherRR MEDICARE
NC8901898Medicaid
NC101405OtherMEDICAL LICENSE
NC101405OtherMEDICAL LICENSE
NC101405OtherMEDICAL LICENSE
NC970010711OtherRR MEDICARE
NC8901898Medicaid