Healthcare Provider Details

I. General information

NPI: 1326281130
Provider Name (Legal Business Name): WHITNEY NICOLE THOMAS SHAMP P.A.- C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WHITNEY NICOLE THOMAS PA - C

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S WOODS MILL RD STE 400E
CHESTERFIELD MO
63017-3406
US

IV. Provider business mailing address

225 BALDWIN AVE
CHARLOTTE NC
28204-3109
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-2888
  • Fax: 314-576-8187
Mailing address:
  • Phone: 704-376-1605
  • Fax: 704-335-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-01840
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01840
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2020009409
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: