Provider Demographics
NPI:1699727727
Name:STALLCOP, SHAWNA L (NP)
Entity type:Individual
Prefix:MRS
First Name:SHAWNA
Middle Name:L
Last Name:STALLCOP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3300
Mailing Address - Street 2:
Mailing Address - City:LAPINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739
Mailing Address - Country:US
Mailing Address - Phone:541-536-3435
Mailing Address - Fax:541-536-8047
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LAPINE
Practice Address - State:OR
Practice Address - Zip Code:97739
Practice Address - Country:US
Practice Address - Phone:541-536-3435
Practice Address - Fax:541-536-8047
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150091NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114703Medicare ID - Type Unspecified
P42846Medicare UPIN