Provider Demographics
NPI:1326562836
Name:HORNBECK, SHANA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:ANN
Last Name:HORNBECK
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 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-9307
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:4061 W 95TH ST STE 3
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2611
Practice Address - Country:US
Practice Address - Phone:708-423-2880
Practice Address - Fax:708-423-2933
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-008212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54633OtherPHYSICIAN ASSISTANT BOARD