Provider Demographics
NPI:1164713632
Name:HAMILTON, SHANNON ELIZABETH (PA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 LAFAYETTE CTR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3943
Mailing Address - Country:US
Mailing Address - Phone:636-707-0764
Mailing Address - Fax:
Practice Address - Street 1:409 LAFAYETTE CTR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63011-3943
Practice Address - Country:US
Practice Address - Phone:636-707-0764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011011827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant