Basic Information
| Provider Information | |||||||||
| NPI: | 1326281130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAMP | ||||||||
| FirstName: | WHITNEY | ||||||||
| MiddleName: | NICOLE THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.- C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | WHITNEY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA - C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 S WOODS MILL RD STE 400E | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148782888 | ||||||||
| FaxNumber: | 3145768187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0010-01840 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 0010-01840 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2020009409 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1326281130 | 05 | NC | MEDICAID | 2342616 | 01 | NC | MEDICARE GROUP PTAN | OTHER | 2760123 | 01 | NC | MEDICARE PTAN | OTHER |