Provider Demographics
NPI:1275701492
Name:PLUMB, SHANNON ALIN (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ALIN
Last Name:PLUMB
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:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74802-0849
Mailing Address - Country:US
Mailing Address - Phone:405-273-5801
Mailing Address - Fax:405-878-3814
Practice Address - Street 1:3315 KETHLEY RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9638
Practice Address - Country:US
Practice Address - Phone:405-273-5801
Practice Address - Fax:405-878-3814
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200131140AMedicaid
OKOK100239Medicare PIN