Provider Demographics
NPI:1497883037
Name:TRUNK - BROKOP, SHANNON L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:TRUNK - BROKOP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:400 S KENNEDY DR
Mailing Address - Street 2:STE 900
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2682
Mailing Address - Country:US
Mailing Address - Phone:815-937-0933
Mailing Address - Fax:815-932-2397
Practice Address - Street 1:400 S KENNEDY DR
Practice Address - Street 2:STE 900
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-2682
Practice Address - Country:US
Practice Address - Phone:815-932-3132
Practice Address - Fax:815-932-2397
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant