Provider Demographics
NPI:1326097395
Name:O'DONLEY, SHAWNA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:O'DONLEY
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:PO BOX 24921
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1921
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:500 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7354
Practice Address - Country:US
Practice Address - Phone:903-870-4122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y0106OtherBLUE CROSS BLUE SHIELD NU
TX8Y1143OtherBLUE CROSS BLUE SHIELD
Q15904Medicare UPIN
TX8J3305Medicare PIN
TX8G6019Medicare PIN
TXP00444676Medicare PIN