Provider Demographics
NPI:1932861705
Name:HEIMANN, SHANNON TAYLOR
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TAYLOR
Last Name:HEIMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-353-9906
Practice Address - Street 1:2930 11TH AVE
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-1011
Practice Address - Country:US
Practice Address - Phone:970-353-9403
Practice Address - Fax:970-353-9906
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-09
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant