Healthcare Provider Details

I. General information

NPI: 1871603902
Provider Name (Legal Business Name): SHANNON C. THISTLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON C MILLER

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 320
COEUR D ALENE ID
83814-4485
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5250
  • Fax: 208-625-5251
Mailing address:
  • Phone: 208-625-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61086741
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA058013
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2265
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: