Healthcare Provider Details

I. General information

NPI: 1023584000
Provider Name (Legal Business Name): SHANNON MARY ZUKOWSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 FANNIN ST
HOUSTON TX
77030-1501
US

IV. Provider business mailing address

6400 FANNIN ST STE 2350
HOUSTON TX
77030-1554
US

V. Phone/Fax

Practice location:
  • Phone: 713-704-4300
  • Fax:
Mailing address:
  • Phone: 713-704-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA031666
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14993
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: