Provider Demographics
NPI:1679548705
Name:BURRIS, SHANNON D (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:BURRIS
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 1:28 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109
Mailing Address - Country:US
Mailing Address - Phone:804-725-4115
Mailing Address - Fax:804-725-4201
Practice Address - Street 1:28 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109
Practice Address - Country:US
Practice Address - Phone:804-725-4115
Practice Address - Fax:804-725-4201
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024134311363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31307Medicare UPIN