Provider Demographics
NPI:1144224932
Name:CALLAWAY, SHANNON BALLARD (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:BALLARD
Last Name:CALLAWAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:CALLAWAY
Other - Last Name:VICKERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 W COUNTRY CLUB RD STE 130
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5249
Mailing Address - Country:US
Mailing Address - Phone:575-625-2669
Mailing Address - Fax:575-624-4632
Practice Address - Street 1:300 W COUNTRY CLUB RD STE 130
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5249
Practice Address - Country:US
Practice Address - Phone:575-625-2669
Practice Address - Fax:575-624-4632
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCOO2607363AM0700X
NMPA2022-0043363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP91975Medicare UPIN
MDKS04L148Medicare ID - Type UnspecifiedPHYSICIAN ASSITANT