Provider Demographics
NPI:1700824638
Name:CHISHOLM, SHANNON DRE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:DRE
Last Name:CHISHOLM
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 1:3706 N ROOSEVELT BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-4566
Mailing Address - Country:US
Mailing Address - Phone:305-517-6613
Mailing Address - Fax:305-517-6614
Practice Address - Street 1:3706 N ROOSEVELT BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4566
Practice Address - Country:US
Practice Address - Phone:305-517-6613
Practice Address - Fax:305-517-6614
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02625363AS0400X
FLPA9107966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216178801Medicaid
TXP00800517OtherRAILROAD MEDICARE
TXP01064726OtherRAILROAD MEDICARE
TXTXB145844Medicare PIN
TXTXB145843Medicare PIN
TXTXB145842Medicare PIN
TX216178801Medicaid
TXP00800517OtherRAILROAD MEDICARE
TXP01064726OtherRAILROAD MEDICARE