Provider Demographics
NPI:1366853525
Name:BURNS, SHANNON (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7103
Mailing Address - Country:US
Mailing Address - Phone:802-878-8131
Mailing Address - Fax:
Practice Address - Street 1:586 OAK HILL RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495
Practice Address - Country:US
Practice Address - Phone:802-878-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH390200000X
VT104.01048482255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer