Provider Demographics
NPI:1932274578
Name:WHITLOCK, SHANNON (PAC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19465 DEERFIELD AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1701
Mailing Address - Country:US
Mailing Address - Phone:703-723-6568
Mailing Address - Fax:703-423-4298
Practice Address - Street 1:19465 DEERFIELD AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-1701
Practice Address - Country:US
Practice Address - Phone:703-723-6568
Practice Address - Fax:703-423-4298
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002157363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
J8110001OtherCAREFIRST
144145OtherANTHEM
321643OtherMAMSI
672614OtherNCPPO
3556360OtherAETNA HMO
7758378OtherAETNA PPO
321643OtherMAMSI