Provider Demographics
NPI:1457635526
Name:WATTS, SHANNON ELLER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ELLER
Last Name:WATTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:RENEE
Other - Last Name:ELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 IRVING ST NW STE 2700N
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2927
Mailing Address - Country:US
Mailing Address - Phone:202-723-5524
Mailing Address - Fax:202-291-0512
Practice Address - Street 1:2002 MEDICAL PKWY STE 500
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3268
Practice Address - Country:US
Practice Address - Phone:410-573-6480
Practice Address - Fax:410-573-9413
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant