MEDICARE: SHANNON SKINNER 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	363A00000X	Physician Assistant	PA07219	TX

General Provider Information

NPI Number	:	1831478965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON SKINNER PA-C

Provider Business Mailing Address
First Line	:	309 CHESTNUT BND
Second Line	:
City	:	COLLEYVILLE
State	:	TX
Zip	:	76034-7608
Country	:	US
Telephone Number	:	817-929-6194
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-7719
Country	:	US
Telephone Number	:	214-905-1461
Fax Number	:

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

Provider Enumeration Date	:	08/07/2011
Last Update Date	:	08/09/2011

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