Provider Demographics
NPI:1033635297
Name:SHANKS, ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:FULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:
Practice Address - Street 1:500 J CLYDE MORRIS BLVD FL ANNEX1
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-3369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-19
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant