Provider Demographics
NPI:1598273708
Name:HUTTON, SHANNON ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:HUTTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 N TENAYA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0464
Mailing Address - Country:US
Mailing Address - Phone:702-252-8378
Mailing Address - Fax:
Practice Address - Street 1:2911 N TENAYA WAY STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0488
Practice Address - Country:US
Practice Address - Phone:702-252-8378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant