Provider Demographics
NPI:1114357274
Name:VASSALLO, SHANNON DOROTHEA (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DOROTHEA
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:NARDOZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3801 WAKE FOREST RD STE 210
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6864
Mailing Address - Country:US
Mailing Address - Phone:919-787-7246
Mailing Address - Fax:919-787-7247
Practice Address - Street 1:3801 WAKE FOREST RD STE 210
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6864
Practice Address - Country:US
Practice Address - Phone:919-787-7246
Practice Address - Fax:919-787-7247
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-04755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant