Provider Demographics
NPI:1326281130
Name:SHAMP, WHITNEY NICOLE THOMAS (PA- C)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:NICOLE THOMAS
Last Name:SHAMP
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:NICOLE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA - C
Mailing Address - Street 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:704-335-8448
Practice Address - Street 1:232 S WOODS MILL RD STE 400E
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3406
Practice Address - Country:US
Practice Address - Phone:314-878-2888
Practice Address - Fax:314-576-8187
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01840363AS0400X, 363A00000X
MO2020009409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1326281130Medicaid
NC2342616OtherMEDICARE GROUP PTAN
NC2760123OtherMEDICARE PTAN
NCNC3715CMedicare PIN