Provider Demographics
NPI:1457339095
Name:HULL, SHANNON E (PAC)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:E
Last Name:HULL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MASON WAY
Mailing Address - Street 2:
Mailing Address - City:SHELL ROCK
Mailing Address - State:IA
Mailing Address - Zip Code:50670-1007
Mailing Address - Country:US
Mailing Address - Phone:319-885-6530
Mailing Address - Fax:319-885-6535
Practice Address - Street 1:502 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALLISON
Practice Address - State:IA
Practice Address - Zip Code:50602
Practice Address - Country:US
Practice Address - Phone:319-267-2759
Practice Address - Fax:319-267-2851
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA9700100773OtherRR MEDICARE
IAS13039Medicare UPIN
IA10386Medicare ID - Type Unspecified