Provider Demographics
NPI:1063857977
Name:MALOUF, SHANNON MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MALOUF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:SWANBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2201 COURAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6733
Mailing Address - Country:US
Mailing Address - Phone:707-784-2001
Mailing Address - Fax:707-784-1494
Practice Address - Street 1:2201 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6733
Practice Address - Country:US
Practice Address - Phone:707-784-2001
Practice Address - Fax:707-784-1494
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant