Basic Information
| Provider Information | |||||||||
| NPI: | 1326133588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | LIZ | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COZART | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | LIZ | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7850 JEFFERSON ST NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5058566320 | ||||||||
| Practice Location | |||||||||
| Address1: | 7850 JEFFERSON ST NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5058566320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2005-0014 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA2005-0014 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 685518 | 05 | NM | MEDICAID |