Healthcare Provider Details

I. General information

NPI: 1457339095
Provider Name (Legal Business Name): SHANNON E HULL PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 LOCUST ST
ALLISON IA
50602
US

IV. Provider business mailing address

1001 MASON WAY
SHELL ROCK IA
50670-1007
US

V. Phone/Fax

Practice location:
  • Phone: 319-267-2759
  • Fax: 319-267-2851
Mailing address:
  • Phone: 319-885-6530
  • Fax: 319-885-6535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001238
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: