Provider Demographics
NPI:1134008840
Name:KOUKOS, SHAUGHN (PA-C)
Entity type:Individual
Prefix:
First Name:SHAUGHN
Middle Name:
Last Name:KOUKOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 TARTON WAY
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-1828
Mailing Address - Country:US
Mailing Address - Phone:772-696-0441
Mailing Address - Fax:
Practice Address - Street 1:2415 N ORANGE AVE STE 502
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5503
Practice Address - Country:US
Practice Address - Phone:407-303-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant