Provider Demographics
NPI:1326133588
Name:SHANNON, SAMANTHA LIZ (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:LIZ
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:LIZ
Other - Last Name:COZART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7850 JEFFERSON ST NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4315
Mailing Address - Country:US
Mailing Address - Phone:505-884-1114
Mailing Address - Fax:505-856-6320
Practice Address - Street 1:7850 JEFFERSON ST NE
Practice Address - Street 2:SUITE 300
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4315
Practice Address - Country:US
Practice Address - Phone:505-884-1114
Practice Address - Fax:505-856-6320
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0014363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM685518Medicaid
NM383310YX2ZMedicare PIN