Provider Demographics
NPI:1669905436
Name:JOHN, SHANA (PA)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:S
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1280 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7509
Mailing Address - Country:US
Mailing Address - Phone:817-310-0898
Mailing Address - Fax:817-310-5524
Practice Address - Street 1:1280 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7509
Practice Address - Country:US
Practice Address - Phone:817-310-0898
Practice Address - Fax:817-310-5524
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant