Provider Demographics
NPI:1740409168
Name:VAN HOUTEN, SHANNAN (PA)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:
Last Name:VAN HOUTEN
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:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-0575
Mailing Address - Country:US
Mailing Address - Phone:209-681-2870
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-681-2870
Practice Address - Fax:209-468-7042
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2012-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21438OtherLICENSE