Provider Demographics
NPI:1639751142
Name:KHATTAK, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KHATTAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5445 DTC PKWY STE 1130
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-3038
Mailing Address - Country:US
Mailing Address - Phone:720-749-5599
Mailing Address - Fax:720-925-5897
Practice Address - Street 1:10375 PARK MEADOWS DR STE 270
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6760
Practice Address - Country:US
Practice Address - Phone:720-749-5599
Practice Address - Fax:720-925-5897
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COPA.0007435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program