Healthcare Provider Details

I. General information

NPI: 1083107973
Provider Name (Legal Business Name): SHANNON J KORTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON J DUNN

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 PIONEER WOODS DR STE 1
LINCOLN NE
68506-7552
US

IV. Provider business mailing address

4130 PIONEER WOODS DR STE 1
LINCOLN NE
68506-7552
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-4700
  • Fax: 402-489-5220
Mailing address:
  • Phone: 402-489-4700
  • Fax: 402-489-5220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2250
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: