Healthcare Provider Details

I. General information

NPI: 1134512197
Provider Name (Legal Business Name): ELIZABETH ANN SHANK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANN YOUNG PA-C

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 09/08/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 PARKWAY DRIVE SUITE 500
HANOVER MD
21076
US

IV. Provider business mailing address

7250 PARKWAY DRIVE SUITE 500
HANOVER MD
21076
US

V. Phone/Fax

Practice location:
  • Phone: 443-949-0814
  • Fax:
Mailing address:
  • Phone: 443-949-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA006216
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC05721
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005721
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: