Provider Demographics
NPI:1710110465
Name:TOWNSEND, SHANNON HOLBERTON (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:HOLBERTON
Last Name:TOWNSEND
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 1:107 WADSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-4521
Mailing Address - Country:US
Mailing Address - Phone:804-330-4901
Mailing Address - Fax:804-330-9141
Practice Address - Street 1:8262 ATLEE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1816
Practice Address - Country:US
Practice Address - Phone:804-559-6194
Practice Address - Fax:804-559-6197
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01912363AM0700X
VA0110004546363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVD728AMedicare PIN
NC0010 01912OtherNORTH CAROLINA MEDICAL BOARD LICENSE