Provider Demographics
NPI:1427080399
Name:MARTIN, SHANNON L (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:
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:PO BOX 14950
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:405-445-1210
Mailing Address - Fax:
Practice Address - Street 1:2821 E HWY 31 E
Practice Address - Street 2:SUITE 101
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702
Practice Address - Country:US
Practice Address - Phone:903-253-9310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2298363AM0700X
TXPA03391363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358865905Medicaid
TX8JM949OtherBCBS
TX8JM948OtherBCBS
TX667700OtherMEDICARE
TXP02056995OtherMEDICARE RAIL ROAD
TXP02057001OtherMEDICARE RAIL ROAD
TX358865904Medicaid