Basic Information
| Provider Information | |||||||||
| NPI: | 1427080399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 E CLARK BASS BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184216960 | ||||||||
| FaxNumber: | 9184216963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA03391 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 2298 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8JM948 | 01 | TX | BCBS | OTHER | 667700 | 01 | TX | MEDICARE | OTHER | 358865905 | 05 | TX | MEDICAID | P02056995 | 01 | TX | MEDICARE RAIL ROAD | OTHER | P02057001 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 358865904 | 05 | TX | MEDICAID | 8JM949 | 01 | TX | BCBS | OTHER |