Provider Demographics
NPI:1205480639
Name:HALLER-BAKER, SHANNON MARIE (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:HALLER-BAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:HALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1531 ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3310
Mailing Address - Country:US
Mailing Address - Phone:530-332-7300
Mailing Address - Fax:
Practice Address - Street 1:2526 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-332-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant