Provider Demographics
NPI:1700824638
Name:CHISHOLM, SHANNON DRE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:DRE
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:PA-C
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 7410884
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0884
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:595 N WILLIAMSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-7185
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:702-977-1496
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02625363AS0400X
FLPA9107966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216178801Medicaid
TXP00800517OtherRAILROAD MEDICARE
TXP01064726OtherRAILROAD MEDICARE
TXTXB145844Medicare PIN
TXTXB145843Medicare PIN
TXTXB145842Medicare PIN
TX216178801Medicaid
TXP00800517OtherRAILROAD MEDICARE
TXP01064726OtherRAILROAD MEDICARE