Basic Information
| Provider Information | |||||||||
| NPI: | 1558393157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONNION | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 MAIN ST N STE 300 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513421039 | ||||||||
| FaxNumber: | 6513421428 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 MAIN ST N STE 300 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513421039 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9510 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | HP40903 | 01 | MN | HEALTHPARTNERS | OTHER | 288675800 | 05 | MN | MEDICAID | 77R94GO | 01 | MN | BCBS | OTHER | 127848 | 01 | MN | UCARE | OTHER | 01-17276 | 01 | MN | MEDICA CHOICE | OTHER | 1043769 | 01 | MN | ARAZ | OTHER | 1023268 | 01 | MN | PREFERRED ONE | OTHER |