1811569270 NPI number — MRS. SHANNON WHITNEY CLARK PHYSICIAN ASSISTANT

Table of content: MRS. SHANNON WHITNEY CLARK PHYSICIAN ASSISTANT (NPI 1811569270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811569270 NPI number — MRS. SHANNON WHITNEY CLARK PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
SHANNON
Provider Middle Name:
WHITNEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811569270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
802 W WHEAT CAPITAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENID
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73701-8756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-573-3088
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 E OWEN K GARRIOTT RD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73701-6153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-599-0648
Provider Business Practice Location Address Fax Number:
580-599-0649
Provider Enumeration Date:
07/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  4606 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: 4606 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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