Basic Information
| Provider Information | |||||||||
| NPI: | 1134512197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7250 PARKWAY DRIVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7250 PARKWAY DRIVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2015 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA006216 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | C05721 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | C0005721 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.