Basic Information
| Provider Information | |||||||||
| NPI: | 1326097395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DONLEY | ||||||||
| FirstName: | SHAWNA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24921 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761241921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SHERMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750927354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038704122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03438 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8Y0106 | 01 | TX | BLUE CROSS BLUE SHIELD NU | OTHER | 8Y1143 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |