Provider Demographics
NPI:1205169547
Name:RAYBURN, SHAWN MONTGOMERY (PA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:MONTGOMERY
Last Name:RAYBURN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 745040
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1307 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-8117
Practice Address - Country:US
Practice Address - Phone:336-832-3110
Practice Address - Fax:336-832-3111
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101052363A00000X
ND101052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant