Provider Demographics
NPI:1750566790
Name:JOHNSON, SHANNON LEE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEE
Last Name:JOHNSON
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 1:1228 E RUSHOLME ST
Mailing Address - Street 2:MOB 1, SUITE 3020
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803
Mailing Address - Country:US
Mailing Address - Phone:563-421-7540
Mailing Address - Fax:563-421-7549
Practice Address - Street 1:1228 E RUSHOLME ST
Practice Address - Street 2:MOB 1, SUITE 3020
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803
Practice Address - Country:US
Practice Address - Phone:563-421-7540
Practice Address - Fax:563-421-7549
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003168363A00000X
IA002328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962481861OtherWELLMARK
1962481861OtherWELLMARK