Provider Demographics
NPI:1104033018
Name:MURILLO, SHANON STAR (PA-C)
Entity type:Individual
Prefix:
First Name:SHANON
Middle Name:STAR
Last Name:MURILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANON
Other - Middle Name:STAR
Other - Last Name:HEATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1694 GUSTAVO STREET
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019
Mailing Address - Country:US
Mailing Address - Phone:619-227-8228
Mailing Address - Fax:
Practice Address - Street 1:2401 REO DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139
Practice Address - Country:US
Practice Address - Phone:619-479-6767
Practice Address - Fax:619-434-8840
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP20292207R00000X
CT001546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid
CT004235900Medicaid