Provider Demographics
NPI:1700824448
Name:RYNDERS, SHANNON LEE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEE
Last Name:RYNDERS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44604 STERLING HWY STE D
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7962
Mailing Address - Country:US
Mailing Address - Phone:907-420-0585
Mailing Address - Fax:
Practice Address - Street 1:44604 STERLING HWY STE D
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7962
Practice Address - Country:US
Practice Address - Phone:907-420-0585
Practice Address - Fax:907-420-0586
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000515A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090430RRRRMedicare ID - Type Unspecified
INP39593Medicare UPIN