Provider Demographics
NPI:1164961629
Name:YOUNGER, SHANNON JOHNSON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:JOHNSON
Last Name:YOUNGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:LUPE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:724 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3098
Mailing Address - Country:US
Mailing Address - Phone:662-328-3375
Mailing Address - Fax:662-328-3395
Practice Address - Street 1:724 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3098
Practice Address - Country:US
Practice Address - Phone:662-328-3375
Practice Address - Fax:662-328-3395
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110198363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9110198Other59-2455010
MSPA00395OtherMISSISSIPPI PA CERTIFICATE