Provider Demographics
NPI:1215258819
Name:DOMANGUE, SHANNON FAGAN (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:FAGAN
Last Name:DOMANGUE
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 1:17450 ST LUKES WAY STE 290
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8045
Mailing Address - Country:US
Mailing Address - Phone:281-296-8500
Mailing Address - Fax:281-296-8591
Practice Address - Street 1:17450 ST LUKES WAY STE 290
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8045
Practice Address - Country:US
Practice Address - Phone:281-296-8500
Practice Address - Fax:281-296-8591
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant