Provider Demographics
NPI:1326006214
Name:HEUTS, SHANNON BRACKETT (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BRACKETT
Last Name:HEUTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 WATERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-8925
Mailing Address - Country:US
Mailing Address - Phone:252-442-7462
Mailing Address - Fax:
Practice Address - Street 1:6411 WATERS EDGE DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-8925
Practice Address - Country:US
Practice Address - Phone:252-442-7462
Practice Address - Fax:252-962-6671
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3510363AS0400X
NC0010-00629363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0805KMedicare ID - Type Unspecified