Provider Demographics
NPI:1780733691
Name:RATHBUN, SHANNON MICHELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:RATHBUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:ULRICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:307 KATHLEEN DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2219
Mailing Address - Country:US
Mailing Address - Phone:925-708-8554
Mailing Address - Fax:
Practice Address - Street 1:1425 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5318
Practice Address - Country:US
Practice Address - Phone:925-295-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16801363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical