Shannon Jackie Clark
Individual provider Active NPI Contractor · Vail, AZ
NPI 1700940855 · NPPES record last updated Dec 26, 2024
Key facts
- NPI
- 1700940855
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Contractor 171W00000X
- License
- 11816 (AZ)
- Practice address
- 12729 S Ox Cart TRL
Vail, AZ 85641-9232 - Phone
- (512) 214-2841
- Fax
- (520) 750-0056
- NPI assigned
- Dec 21, 2006
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11816 | AZ | MD | Physician Assistant |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Contractor | 171W00000X | 11816 | AZ | Yes |
Addresses
Primary practice location
12729 S Ox Cart TRL
Vail, AZ 85641-9232
Mailing address
12729 S Ox Cart TRL
Vail, AZ 85641-9232
Phone (512) 214-2841
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 162753 | Medicaid | AZ |
Other providers in Vail, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 26, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.