Provider Demographics
NPI:1225012578
Name:HAUSCHILDT, SHANNON M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:HAUSCHILDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1155 W. PARKVIEW ST.
Mailing Address - Street 2:SUITE 2 D
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-7800
Mailing Address - Country:US
Mailing Address - Phone:417-777-2663
Mailing Address - Fax:417-777-2666
Practice Address - Street 1:1155 W. PARKVIEW ST.
Practice Address - Street 2:SUITE 2 D
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-7800
Practice Address - Country:US
Practice Address - Phone:417-777-2663
Practice Address - Fax:417-777-2666
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004003730363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097097Medicare ID - Type Unspecified
Q16454Medicare UPIN