Basic Information
| Provider Information | |||||||||
| NPI: | 1588879944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHONK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EARL | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18824 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274198824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 DARLING AVE | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315015246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123386511 | ||||||||
| FaxNumber: | 9123386512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 1564 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 005166 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 67.000131 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 655272915A | 05 | GA | MEDICAID |