Provider Demographics
NPI:1093903270
Name:O'ROARK, SHANA S (RN, FNP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:S
Last Name:O'ROARK
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:S
Other - Last Name:PESCHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:200 OCEANGATE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-435-3666
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:1255 W 15TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7262
Practice Address - Country:US
Practice Address - Phone:888-562-5442
Practice Address - Fax:562-499-6171
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX620562363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191807001Medicaid
TX191807001Medicaid
TX8K2952Medicare PIN