Provider Demographics
NPI:1386606028
Name:ERVIN, SHANNON RUTH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RUTH
Last Name:ERVIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:RUTH
Other - Last Name:LOWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:704-332-5206
Practice Address - Street 1:3623 LATROBE DR
Practice Address - Street 2:SUITE 216
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:704-332-5206
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1035802085R0204X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2757012Medicare ID - Type Unspecified
P72027Medicare UPIN