Provider Demographics
NPI:1821243684
Name:THURSTON, SHANNON TAYLOR (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:TAYLOR
Last Name:THURSTON
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 1:6405 S 3000 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6977
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:
Practice Address - Street 1:585 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:UT
Practice Address - Zip Code:84525
Practice Address - Country:US
Practice Address - Phone:435-564-3434
Practice Address - Fax:435-564-3214
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7154120-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical