Healthcare Provider Details

I. General information

NPI: 1902523905
Provider Name (Legal Business Name): SHANNON HARRIS VANANTWERP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 WICKS LN
BILLINGS MT
59105-4427
US

IV. Provider business mailing address

PO BOX 35100
BILLINGS MT
59107-5100
US

V. Phone/Fax

Practice location:
  • Phone: 406-238-2900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-117108
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: