Provider Demographics
NPI:1770560161
Name:CARMOUCHE, SHANNAN LEE (PA)
Entity type:Individual
Prefix:MRS
First Name:SHANNAN
Middle Name:LEE
Last Name:CARMOUCHE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:LEE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9800 BROADWAY EXTENSION
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114
Mailing Address - Country:US
Mailing Address - Phone:405-419-5412
Mailing Address - Fax:405-419-5468
Practice Address - Street 1:9800 BROADWAY EXTENSION
Practice Address - Street 2:SUITE 203
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114
Practice Address - Country:US
Practice Address - Phone:405-419-5412
Practice Address - Fax:405-419-5468
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1162208600000X, 2086S0129X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK243405602Medicare UPIN
OK100132460AMedicaid
OKP53945Medicare UPIN