Healthcare Provider Details

I. General information

NPI: 1073940649
Provider Name (Legal Business Name): SHANNA M LITTEKEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNA M STRIEKER PA-C

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S KIRKWOOD RD SUITE 200
SAINT LOUIS MO
63122-6161
US

IV. Provider business mailing address

1094 N 9TH ST
BREESE IL
62230-1364
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-1666
  • Fax: 314-909-7406
Mailing address:
  • Phone: 618-304-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004836
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: