Provider Demographics
NPI:1083107973
Name:KORTH, SHANNON J (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:KORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:J
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4130 PIONEER WOODS DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7552
Mailing Address - Country:US
Mailing Address - Phone:402-489-4700
Mailing Address - Fax:402-489-5220
Practice Address - Street 1:4130 PIONEER WOODS DR STE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-7552
Practice Address - Country:US
Practice Address - Phone:402-489-4700
Practice Address - Fax:402-489-5220
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2250OtherMEDICAL LICENSE