Healthcare Provider Details

I. General information

NPI: 1366853525
Provider Name (Legal Business Name): SHANNON BURNS PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 OAK HILL RD
WILLISTON VT
05495
US

IV. Provider business mailing address

586 OAK HILL RD
WILLISTON VT
05495-7103
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-8131
  • Fax:
Mailing address:
  • Phone: 802-878-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0104848
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: