Provider Demographics
NPI:1013979079
Name:BENNETT, SHANON DIONE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANON
Middle Name:DIONE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANON
Other - Middle Name:DIONE
Other - Last Name:ROELFS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1731 W RIDGEWAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4591
Mailing Address - Country:US
Mailing Address - Phone:319-833-5888
Mailing Address - Fax:319-833-5891
Practice Address - Street 1:1731 W RIDGEWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4591
Practice Address - Country:US
Practice Address - Phone:319-833-5888
Practice Address - Fax:319-833-5891
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000136363AM0700X
IA001016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA970024832OtherRR MEDICARE