Provider Demographics
NPI:1598103111
Name:WALLACE, SHANNON R (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5818 D HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3327
Mailing Address - Country:US
Mailing Address - Phone:757-215-1400
Mailing Address - Fax:757-215-1403
Practice Address - Street 1:5818 D HARBOUR VIEW BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3327
Practice Address - Country:US
Practice Address - Phone:757-215-1400
Practice Address - Fax:757-215-1403
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110004256363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant