Basic Information
| Provider Information | |||||||||
| NPI: | 1588698278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BORDT-SCANGO | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 859 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MALTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437589007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409626111 | ||||||||
| FaxNumber: | 7409622182 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 S 15TH ST | ||||||||
| Address2: | |||||||||
| City: | COSHOCTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438122285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402953331 | ||||||||
| FaxNumber: | 7402953332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA051578 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.004688RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.