Provider Demographics
NPI:1720250087
Name:RUTH, SHANNON ALEXANDER (PA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ALEXANDER
Last Name:RUTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 HAYS ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-3207
Mailing Address - Country:US
Mailing Address - Phone:830-875-3445
Mailing Address - Fax:830-875-3765
Practice Address - Street 1:130 HAYS ST
Practice Address - Street 2:SUITE D
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-3207
Practice Address - Country:US
Practice Address - Phone:830-875-3445
Practice Address - Fax:830-875-3765
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05863363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280084902Medicaid
TXTXB156153Medicare PIN