Provider Demographics
NPI:1649208935
Name:MORTON, SHANNON (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MORTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W BOILING SPRING RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9730
Mailing Address - Country:US
Mailing Address - Phone:910-845-5333
Mailing Address - Fax:910-845-5366
Practice Address - Street 1:201 W BOILING SPRING RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9730
Practice Address - Country:US
Practice Address - Phone:910-845-5333
Practice Address - Fax:910-845-5366
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00305363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101787Medicaid
NCP00398292OtherRAILROAD MEDICARE
NC5911685Medicaid
SCT70857Medicaid
NCNC2010JMedicare PIN
NCP00398292OtherRAILROAD MEDICARE
NCNC2010BMedicare PIN
SCT70857Medicaid
NCNC2010DMedicare PIN
NCNC2010LMedicare PIN
NCNC2010MMedicare PIN
NC8101787Medicaid
NCNC2010EMedicare PIN
NCNC2010GMedicare PIN
NCNC2010KMedicare PIN
NCNC2010CMedicare PIN