Provider Demographics
NPI:1528353711
Name:PANKRATZ, SHAUNA MARISSA
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:MARISSA
Last Name:PANKRATZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 126TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2512
Mailing Address - Country:US
Mailing Address - Phone:651-336-9254
Mailing Address - Fax:
Practice Address - Street 1:8232 HIGHWAY 65 NE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-2095
Practice Address - Country:US
Practice Address - Phone:763-577-1877
Practice Address - Fax:763-577-1887
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant