Provider Demographics
NPI:1164405791
Name:AUTREY, SHANNA MICHELE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:MICHELE
Last Name:AUTREY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 UNDERCLIFF TER
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2174
Mailing Address - Country:US
Mailing Address - Phone:304-431-3010
Mailing Address - Fax:304-431-3011
Practice Address - Street 1:160 UNDERCLIFF TER
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2174
Practice Address - Country:US
Practice Address - Phone:304-431-3010
Practice Address - Fax:304-431-3011
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA15013Medicare ID - Type Unspecified
WVS99180Medicare UPIN