Basic Information
| Provider Information | |||||||||
| NPI: | 1053941351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNNELL | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | TREVOR | ||||||||
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| Credential: | AGNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3282 S 1380 W | ||||||||
| Address2: | |||||||||
| City: | NIBLEY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843217953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358905553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1537 ELMIRA ST | ||||||||
| Address2: | |||||||||
| City: | SAYRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188409254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708243521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2020 | ||||||||
| LastUpdateDate: | 02/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 8315670-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.