Provider Demographics
NPI:1427627132
Name:ROSENBROCK, SHANNON (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROSENBROCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CARDIOTHORACIC AND VASCULAR SURGICAL ASSOCIATES SC
Mailing Address - Street 2:4400 W 95TH STREET SUITE 308
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2660
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:657 PASADENA AVE
Practice Address - Street 2:
Practice Address - City:BEECHER
Practice Address - State:IL
Practice Address - Zip Code:60401-3611
Practice Address - Country:US
Practice Address - Phone:815-671-9279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty