Provider Demographics
NPI:1770848400
Name:MAYBERRY, SHANNON POPLSTEIN (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:POPLSTEIN
Last Name:MAYBERRY
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 1:7 PEGRAM CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-7970
Mailing Address - Country:US
Mailing Address - Phone:540-761-8091
Mailing Address - Fax:
Practice Address - Street 1:3711 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2654
Practice Address - Country:US
Practice Address - Phone:919-752-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03634363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant