Healthcare Provider Details

I. General information

NPI: 1639751142
Provider Name (Legal Business Name): SHANNON KHATTAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON OLIVER PA-C

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10375 PARK MEADOWS DR STE 270
LONE TREE CO
80124-6760
US

IV. Provider business mailing address

5445 DTC PKWY STE 1130
GREENWOOD VILLAGE CO
80111-3038
US

V. Phone/Fax

Practice location:
  • Phone: 720-749-5599
  • Fax: 720-925-5897
Mailing address:
  • Phone: 720-749-5599
  • Fax: 720-925-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0007435
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: