Provider Demographics
NPI:1689943870
Name:DELLOIACONO, SHANNON NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:DELLOIACONO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:WOLTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1809 E 13TH ST
Mailing Address - Street 2:STE. 400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4419
Mailing Address - Country:US
Mailing Address - Phone:918-599-8200
Mailing Address - Fax:918-583-4678
Practice Address - Street 1:1809 E 13TH ST
Practice Address - Street 2:STE. 400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4419
Practice Address - Country:US
Practice Address - Phone:918-599-8200
Practice Address - Fax:918-583-4678
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1102551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200511350AMedicaid
OK319282YLV0Medicare PIN