Provider Demographics
NPI:1336420561
Name:HAILEY, SHANNON K (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:HAILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10777 NALL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1330
Mailing Address - Country:US
Mailing Address - Phone:913-563-6630
Mailing Address - Fax:913-563-6699
Practice Address - Street 1:10777 NALL AVE STE 300
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1330
Practice Address - Country:US
Practice Address - Phone:913-563-6630
Practice Address - Fax:913-563-6699
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015010264363AS0400X
KS15-01479363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical