Healthcare Provider Details

I. General information

NPI: 1700824448
Provider Name (Legal Business Name): SHANNON LEE RYNDERS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44604 STERLING HWY STE D
SOLDOTNA AK
99669-7962
US

IV. Provider business mailing address

44604 STERLING HWY STE D
SOLDOTNA AK
99669-7962
US

V. Phone/Fax

Practice location:
  • Phone: 907-420-0585
  • Fax: 907-420-0586
Mailing address:
  • Phone: 907-420-0585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000515A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: