Provider Demographics
NPI:1528472818
Name:HOLLOMAN, SHANNON K (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:HOLLOMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:ANDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:600 GRESHAM DR STE 204
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-5680
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR STE 204
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-5680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004593363A00000X
VA0110-004593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528472818OtherHUMANA
VA1528472818OtherTRICARE
VA10160253POtherOPTIMA HEALTH
VA565258OtherBLUE CROSS BLUE SHIELD SUPPLEMENT
VA1528472818Medicaid