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General NPI Number Information
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NPI Number | 1932274578
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Entity Type | Individual
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Provider Name | SHANNON WHITLOCK PAC
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Gender | Female
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 04/24/2025
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Provider Practice Location Address
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Address Line | 830 AINSWORTH DR
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City | PRESCOTT
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State | AZ
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Zip | 86301-1630
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Country | US
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Telephone | 928-777-5800
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Fax | 928-776-0405
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Provider Business Mailing Address
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Address Line | 801 YORK ST
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City | MANITOWOC
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State | WI
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Zip | 54220-4630
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Country | US
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Telephone | 920-663-9008
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Fax | 920-684-1439
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0110002157
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 10942
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License Number State | AZ
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