Provider Demographics
NPI:1942276662
Name:WHITEHEAD, SHANA L (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:L
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:L
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1910
Mailing Address - Country:US
Mailing Address - Phone:217-243-9471
Mailing Address - Fax:217-243-5359
Practice Address - Street 1:800 W STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1910
Practice Address - Country:US
Practice Address - Phone:217-243-9471
Practice Address - Fax:217-243-5359
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK08402Medicare ID - Type Unspecified
Q20691Medicare UPIN