Healthcare Provider Details

I. General information

NPI: 1710094958
Provider Name (Legal Business Name): SHANNON B MURRELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5447 MAPLE LN SUITE B
FAYETTEVILLE WV
25840-6872
US

IV. Provider business mailing address

5447 MAPLE LN SUITE B
FAYETTEVILLE WV
25840-6872
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-6900
  • Fax:
Mailing address:
  • Phone: 304-574-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA941
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: