Provider Demographics
NPI:1851477574
Name:EVANS, SHANNON (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:EVANS
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 398
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-0398
Mailing Address - Country:US
Mailing Address - Phone:910-862-5100
Mailing Address - Fax:910-862-1238
Practice Address - Street 1:501 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9375
Practice Address - Country:US
Practice Address - Phone:910-862-5100
Practice Address - Fax:910-862-1238
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC100592OtherSTATE LICENSE NC
NCQ07462Medicare UPIN
NC100592OtherSTATE LICENSE NC