| NPI | 1053744425 |
|---|---|
| Former Name | SHANNON NICOLE WANICHKO |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA058204) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003787) |
| 363AM0700X Physician Assistant, Medical (Licence: IL 085004752) | |
| Enumeration Date | 2013-08-20 |
| Last Update Date | 2019-04-09 |