Provider Demographics
NPI:1871609636
Name:SPILLER, SHANNON MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:SPILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:P.O. BOX 1229
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093
Mailing Address - Country:US
Mailing Address - Phone:530-623-4186
Mailing Address - Fax:530-623-4397
Practice Address - Street 1:60 EASTER AVE
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093
Practice Address - Country:US
Practice Address - Phone:530-623-4186
Practice Address - Fax:530-623-4397
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9562207Q00000X, 363A00000X
CAPA15036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN378617000Medicaid
MN378617000Medicaid