Provider Demographics
NPI:1972827301
Name:SHANKLIN, AMANDA JANE (MPAP, PA-C)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:JANE
Last Name:SHANKLIN
Suffix:
Gender:F
Credentials:MPAP, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22431 ANTONIO PKWY # B160-613
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2804
Mailing Address - Country:US
Mailing Address - Phone:833-477-2677
Mailing Address - Fax:833-477-2677
Practice Address - Street 1:22431 ANTONIO PKWY # B160-613
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2804
Practice Address - Country:US
Practice Address - Phone:833-477-2677
Practice Address - Fax:833-477-2677
Is Sole Proprietor?:No
Enumeration Date:2010-03-14
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20964363AS0400X
CAPA20694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20964OtherCA LICENSE
CAPA20964OtherCA LICENSE
CADM680ZMedicare PIN