Provider Demographics
NPI:1326075078
Name:NELSON, SHANNON M (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:13133 N PORT WASHINGTON RD STE 204
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2420
Practice Address - Country:US
Practice Address - Phone:262-243-2524
Practice Address - Fax:262-243-2525
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1326075078Medicaid
WI736450066Medicare PIN