Healthcare Provider Details

I. General information

NPI: 1932274578
Provider Name (Legal Business Name): SHANNON WHITLOCK PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 AINSWORTH DR
PRESCOTT AZ
86301-1630
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-5800
  • Fax: 928-776-0405
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110002157
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10942
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: