Provider Demographics
NPI:1538365184
Name:WATERS, SHANNON KAY (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:KAY
Last Name:WATERS
Suffix:
Gender:F
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 1:322 MULBERRY ST SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5702
Mailing Address - Country:US
Mailing Address - Phone:828-757-6460
Mailing Address - Fax:828-759-4901
Practice Address - Street 1:322 MULBERRY ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5702
Practice Address - Country:US
Practice Address - Phone:828-757-6460
Practice Address - Fax:828-759-4901
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101692363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC081159OtherSTATE NURSING LICENSE
NC101692OtherSTATE LICENSE
NC101692OtherSTATE LICENSE
NCNC3856AMedicare PIN