Provider Demographics
NPI:1174606289
Name:MOFFETT, SHANNON L (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DIVISION OF PULMONARY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6426
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF PULMONARY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-984-5650
Practice Address - Fax:601-984-5658
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857161363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06188884Medicaid
MSP01648526OtherRAILROAD MEDICARE PTAN
MS06188884Medicaid
MS302I506454Medicare PIN