Provider Demographics
NPI:1588698278
Name:WILKINS, SHANNON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:WILKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BORDT-SCANGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:859 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9007
Mailing Address - Country:US
Mailing Address - Phone:740-962-6111
Mailing Address - Fax:740-962-2182
Practice Address - Street 1:406 S 15TH ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2285
Practice Address - Country:US
Practice Address - Phone:740-295-3331
Practice Address - Fax:740-295-3332
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051578363A00000X
OH50.004688RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant