Provider Demographics
NPI:1043796675
Name:RODRIGUEZ, SHANNON ROSE (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0915
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6185
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0915
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6185
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant