Provider Demographics
NPI:1265557060
Name:CARBONNIERE, SHAWNA RENEE (PA)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:RENEE
Last Name:CARBONNIERE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:RENEE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5281 N 99TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2209
Mailing Address - Country:US
Mailing Address - Phone:623-516-8252
Mailing Address - Fax:623-516-8253
Practice Address - Street 1:3110 CLEARWATER DR STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7177
Practice Address - Country:US
Practice Address - Phone:623-516-8252
Practice Address - Fax:623-516-8253
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3516363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical