Healthcare Provider Details

I. General information

NPI: 1881020238
Provider Name (Legal Business Name): SHANNON E SMITH CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON EDDINS

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MARY ST STE 520
EVANSVILLE IN
47710-1682
US

IV. Provider business mailing address

520 MARY ST STE 520
EVANSVILLE IN
47710-1682
US

V. Phone/Fax

Practice location:
  • Phone: 812-424-8231
  • Fax: 812-435-8794
Mailing address:
  • Phone: 812-424-8231
  • Fax: 812-435-8794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: