Provider Demographics
NPI:1386896793
Name:BACKES, SHANNON K (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:BACKES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:D
Other - Last Name:KRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:27650 FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3845
Mailing Address - Country:US
Mailing Address - Phone:630-225-2663
Mailing Address - Fax:630-225-2399
Practice Address - Street 1:27650 FERRY RD
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3845
Practice Address - Country:US
Practice Address - Phone:630-225-2663
Practice Address - Fax:630-225-2399
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00704413OtherMEDICARE RAILROAD
ILP00704413OtherMEDICARE RAILROAD