Provider Demographics
NPI:1134748080
Name:RASMUSSEN, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RASMUSSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:RASMUSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8345 FIRESTONE BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3872
Mailing Address - Country:US
Mailing Address - Phone:562-923-3001
Mailing Address - Fax:562-904-0321
Practice Address - Street 1:8345 FIRESTONE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3872
Practice Address - Country:US
Practice Address - Phone:562-923-3001
Practice Address - Fax:562-904-0321
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7680341-1206363AM0700X
CA59765363A00000X
ORPA200776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty