Healthcare Provider Details

I. General information

NPI: 1811569270
Provider Name (Legal Business Name): SHANNON WHITNEY CLARK PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 E OWEN K GARRIOTT RD STE D
ENID OK
73701-6153
US

IV. Provider business mailing address

802 W WHEAT CAPITAL RD
ENID OK
73701-8756
US

V. Phone/Fax

Practice location:
  • Phone: 580-599-0648
  • Fax: 580-599-0649
Mailing address:
  • Phone: 316-573-3088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4606
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4606
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: