Provider Demographics
NPI:1346531928
Name:PECK, SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PECK
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 1:1159 E 200 N
Mailing Address - Street 2:#250
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2022
Mailing Address - Country:US
Mailing Address - Phone:801-855-2980
Mailing Address - Fax:
Practice Address - Street 1:1159 E 200 N
Practice Address - Street 2:#250
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2022
Practice Address - Country:US
Practice Address - Phone:801-855-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7890710-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant