Provider Demographics
NPI:1891280988
Name:BERNBAUM, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BERNBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18400 KATY FWY
Mailing Address - Street 2:STE 530
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77094-1376
Mailing Address - Country:US
Mailing Address - Phone:281-717-4003
Mailing Address - Fax:281-206-7597
Practice Address - Street 1:18400 KATY FWY STE 530
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77094-1376
Practice Address - Country:US
Practice Address - Phone:281-717-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant