Healthcare Provider Details

I. General information

NPI: 1609035351
Provider Name (Legal Business Name): SHAWN PATRICK EMMONS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2008
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2580
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-2606
  • Fax: 910-815-5698
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number250653
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number250653
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2022-00593
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: