Provider Demographics
NPI:1083662225
Name:BOCK, SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12596 W BAYAUD AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2018
Mailing Address - Country:US
Mailing Address - Phone:720-713-1885
Mailing Address - Fax:
Practice Address - Street 1:403 SUMMIT BLVD
Practice Address - Street 2:STE 201
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021
Practice Address - Country:US
Practice Address - Phone:303-429-6448
Practice Address - Fax:303-951-3701
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37780Medicare UPIN
COC803965Medicare PIN
COQ37780Medicare UPIN
CO803965Medicare ID - Type Unspecified