Provider Demographics
NPI:1245317502
Name:KOVALCIK, SHANNON M (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:KOVALCIK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24431 N 38TH TER
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3360
Mailing Address - Country:US
Mailing Address - Phone:623-399-8717
Mailing Address - Fax:
Practice Address - Street 1:4840 E INDIAN SCHOOL RD STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-5500
Practice Address - Country:US
Practice Address - Phone:602-224-6174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2427363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN PROCESSMedicare UPIN