Provider Demographics
NPI:1053941351
Name:BUNNELL, SHAWN TREVOR (AGNP)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:TREVOR
Last Name:BUNNELL
Suffix:
Gender:M
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3282 S 1380 W
Mailing Address - Street 2:
Mailing Address - City:NIBLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84321-7953
Mailing Address - Country:US
Mailing Address - Phone:435-890-5553
Mailing Address - Fax:
Practice Address - Street 1:1537 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-9254
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-25
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8315670-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health