Provider Demographics
NPI:1932274578
Name:WHITLOCK, SHANNON (PAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:830 AINSWORTH DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1630
Practice Address - Country:US
Practice Address - Phone:928-777-5800
Practice Address - Fax:928-776-0405
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002157363AM0700X
AZ10942363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173121Medicaid
144145OtherANTHEM
321643OtherMAMSI
672614OtherNCPPO
3556360OtherAETNA HMO
7758378OtherAETNA PPO
321643OtherMAMSI