MEDICARE: MS. SAMANTHA LIZ SHANNON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA2005-0014	NM
2	363A00000X	Physician Assistant	PA2005-0014	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326133588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SAMANTHA LIZ SHANNON PA-C

Provider Business Mailing Address
First Line	:	7850 JEFFERSON ST NE
Second Line	:	SUITE 300
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4315
Country	:	US
Telephone Number	:	505-884-1114
Fax Number	:	505-856-6320

Provider Business Practice Location Address
First Line	:	7850 JEFFERSON ST NE
Second Line	:	SUITE 300
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4315
Country	:	US
Telephone Number	:	505-884-1114
Fax Number	:	505-856-6320

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/14/2015

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