Provider Demographics
NPI:1316175037
Name:THOM, SHANNON T (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:T
Last Name:THOM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:T
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 KINCAID ST.
Mailing Address - Street 2:SKAGIT REGIONAL CLINICS
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:3927 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4833
Practice Address - Country:US
Practice Address - Phone:425-259-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200941252RN163W00000X
WAAP60081915363LF0000X, 363L00000X
OR200950065NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619915113OtherCLINIC GROUP NPI
OR213342Medicaid
1619915113OtherCLINIC GROUP NPI