Provider Demographics
NPI:1336363381
Name:SHOOK, KELLY (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHOOK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-8870
Mailing Address - Country:US
Mailing Address - Phone:512-462-3627
Mailing Address - Fax:512-462-3431
Practice Address - Street 1:4303 VICTORY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-8870
Practice Address - Country:US
Practice Address - Phone:512-462-3627
Practice Address - Fax:512-462-3431
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant