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General NPI Number Information
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NPI Number | 1740409168
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Entity Type | Individual
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Provider Name | SHANNAN VAN HOUTEN PA
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Gender | Female
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 11/18/2012
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Provider Practice Location Address
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Address Line | 1441 FLORIDA AVE
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City | MODESTO
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State | CA
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Zip | 95350-4404
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Country | US
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Telephone | 209-681-2870
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Fax | 209-468-7042
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Provider Business Mailing Address
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Address Line | PO BOX 575
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City | ESCALON
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State | CA
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Zip | 95320-0575
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Country | US
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Telephone | 209-681-2870
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Fax | 209-468-7042
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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 | PA21438
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License Number State | CA
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