Provider Demographics
NPI:1598146623
Name:SWIFT, SHANNON OPEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:OPEL
Last Name:SWIFT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:OPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:920-497-7783
Mailing Address - Fax:920-497-7789
Practice Address - Street 1:2301 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:ASHWAUBENON
Practice Address - State:WI
Practice Address - Zip Code:54304-5230
Practice Address - Country:US
Practice Address - Phone:920-497-7783
Practice Address - Fax:920-497-7789
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI3632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100047539Medicaid
WIK400239771OtherMEDICARE PTAN