Provider Demographics
NPI:1184320202
Name:SKINNER, SHAWN DAVID
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DAVID
Last Name:SKINNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 S ST MIHIEL CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0225
Mailing Address - Country:US
Mailing Address - Phone:321-961-1778
Mailing Address - Fax:
Practice Address - Street 1:3127 S ST MIHIEL CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-0225
Practice Address - Country:US
Practice Address - Phone:321-961-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker