Healthcare Provider Details

I. General information

NPI: 1104033018
Provider Name (Legal Business Name): SHANON STAR MURILLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANON STAR HEATON PA-C

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 REO DRIVE
SAN DIEGO CA
92139
US

IV. Provider business mailing address

1694 GUSTAVO STREET
EL CAJON CA
92019
US

V. Phone/Fax

Practice location:
  • Phone: 619-479-6767
  • Fax: 619-434-8840
Mailing address:
  • Phone: 619-227-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001546
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP20292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: