Provider Demographics
NPI:1427515311
Name:ROSE, SHANNON RENE' (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENE'
Last Name:ROSE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N. IH-35, SUITE 700
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:512-807-3150
Mailing Address - Fax:512-458-7879
Practice Address - Street 1:3000 N. IH-35, SUITE 700
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1852
Practice Address - Country:US
Practice Address - Phone:512-807-3150
Practice Address - Fax:512-458-7879
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140791363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty