Provider Demographics
NPI:1124361605
Name:ZWICK, SHANNA MARIE (PA)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:MARIE
Last Name:ZWICK
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-454-7177
Mailing Address - Fax:888-425-7946
Practice Address - Street 1:1044 N MASON RD
Practice Address - Street 2:DIV SURG COLON/RECTAL, STE 310
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6431
Practice Address - Country:US
Practice Address - Phone:314-454-7177
Practice Address - Fax:888-425-7946
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022023073363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220031343Medicaid
MO1124361605Medicaid