Healthcare Provider Details

I. General information

NPI: 1326006214
Provider Name (Legal Business Name): SHANNON BRACKETT HEUTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 WATERS EDGE DR
ROCKY MOUNT NC
27803-8925
US

IV. Provider business mailing address

6411 WATERS EDGE DR
ROCKY MOUNT NC
27803-8925
US

V. Phone/Fax

Practice location:
  • Phone: 252-442-7462
  • Fax: 252-962-6671
Mailing address:
  • Phone: 252-442-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 3510
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-00629
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00629
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: