Provider Demographics
NPI:1952576191
Name:CHAVEZ, SHANNON CAROLINA (PAC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:CAROLINA
Last Name:CHAVEZ
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 1:1359 WEST AVENUE J
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-726-5000
Mailing Address - Fax:
Practice Address - Street 1:1359 WEST AVENUE J
Practice Address - Street 2:HARIHAR P AGARWAL MA INC VALLEY INFANT PEDIATRIC & COMP
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-726-5000
Practice Address - Fax:661-726-4347
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ05207Medicare UPIN