Healthcare Provider Details

I. General information

NPI: 1538367362
Provider Name (Legal Business Name): SHANNON E MILLER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON E YOUNG PAC

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 N CHELAN AVE
WENATCHEE WA
98801-2028
US

IV. Provider business mailing address

820 N CHELAN AVE
WENATCHEE WA
98801-2028
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-8711
  • Fax:
Mailing address:
  • Phone: 509-663-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60646227
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50001694
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: