Provider Demographics
NPI:1912640558
Name:PAO, SHANNY SOTHIDA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNY
Middle Name:SOTHIDA
Last Name:PAO
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 1:2302 TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77093-6731
Mailing Address - Country:US
Mailing Address - Phone:281-272-0888
Mailing Address - Fax:
Practice Address - Street 1:9130 SOUTH TEXAS 6
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083
Practice Address - Country:US
Practice Address - Phone:409-996-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant