Healthcare Provider Details

I. General information

NPI: 1932198439
Provider Name (Legal Business Name): SHAWN TERRENCE LOCKETT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HHC 18TH MEDCOM BOX 592 UNIT 15281
APO AP
96205-0054
US

IV. Provider business mailing address

CMR 420 BOX 2452
APO AE
09063
US

V. Phone/Fax

Practice location:
  • Phone: 971-645-4334
  • Fax:
Mailing address:
  • Phone: 971-645-4334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: