Provider Demographics
NPI:1568842482
Name:BITZA, SHANNON
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:BITZA
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:FOGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8501 N 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4919
Mailing Address - Country:US
Mailing Address - Phone:623-939-1439
Mailing Address - Fax:623-939-1439
Practice Address - Street 1:8501 N 51ST AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4919
Practice Address - Country:US
Practice Address - Phone:623-939-1439
Practice Address - Fax:623-939-1439
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP78632084N0400X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty