Basic Information
| Provider Information | |||||||||
| NPI: | 1265002919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APRN, CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 277 BUDDY GANEM DR STE A | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783743202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617773900 | ||||||||
| FaxNumber: | 3614130274 | ||||||||
| Practice Location | |||||||||
| Address1: | 9139 WESTOVER HILLS BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782512889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104373990 | ||||||||
| FaxNumber: | 2104373991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2021 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 1045865 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.