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General NPI Number Information
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NPI Number | 1104109370
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Entity Type | Individual
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Provider Name | SHANNON ELISABETH PERCIVAL PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/23/2011
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Last Update Date | 09/23/2011
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Provider Practice Location Address
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Address Line | 202 N DIVISION ST
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City | AUBURN
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State | WA
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Zip | 98001-4939
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Country | US
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Telephone | 253-333-2564
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Fax |
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Provider Business Mailing Address
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Address Line | 4950 CORSON AVE S
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City | SEATTLE
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State | WA
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Zip | 98108-1835
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Country | US
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Telephone | 206-799-9647
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA60246035
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License Number State | WA
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