Provider Demographics
NPI:1164655171
Name:AGENBROAD-ELANDER, SHAWN R (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:R
Last Name:AGENBROAD-ELANDER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7507
Mailing Address - Country:US
Mailing Address - Phone:512-462-3627
Mailing Address - Fax:512-462-2898
Practice Address - Street 1:4303 VICTORY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7507
Practice Address - Country:US
Practice Address - Phone:512-462-3627
Practice Address - Fax:512-462-2898
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP118041OtherLICENSE