Provider Demographics
NPI:1932198439
Name:LOCKETT, SHAWN TERRENCE (PA)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:TERRENCE
Last Name:LOCKETT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 420 BOX 2452
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09063
Mailing Address - Country:US
Mailing Address - Phone:971-645-4334
Mailing Address - Fax:
Practice Address - Street 1:HHC 18TH MEDCOM BOX 592 UNIT 15281
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-0054
Practice Address - Country:US
Practice Address - Phone:971-645-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant