Provider Demographics
NPI:1871824219
Name:LEE, SHANNON K (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 HERITAGE WAY
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3158
Mailing Address - Country:US
Mailing Address - Phone:406-752-6784
Mailing Address - Fax:406-756-4111
Practice Address - Street 1:350 HERITAGE WAY
Practice Address - Street 2:SUITE 1200
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3158
Practice Address - Country:US
Practice Address - Phone:406-752-6784
Practice Address - Fax:406-756-4111
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1871824219Medicaid
MT1871824219OtherBCBS
MT1871824219OtherBCBS