Provider Demographics
NPI:1184082273
Name:POGUE, SHANNON (APRN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:POGUE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-9594
Mailing Address - Country:US
Mailing Address - Phone:870-994-7301
Mailing Address - Fax:870-994-7488
Practice Address - Street 1:10144 HIGHWAY 63 N STE A
Practice Address - Street 2:
Practice Address - City:BONO
Practice Address - State:AR
Practice Address - Zip Code:72416-7676
Practice Address - Country:US
Practice Address - Phone:870-520-6069
Practice Address - Fax:870-994-7488
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner