Healthcare Provider Details

I. General information

NPI: 1023678620
Provider Name (Legal Business Name): SHANNON LYNN WATTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON LYNN WOOD

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

1464 ROCKRIDGE RD
JARRETTSVILLE MD
21084-1302
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-2200
  • Fax:
Mailing address:
  • Phone: 443-981-9539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007101
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0007101
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0007101
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: