Provider Demographics
NPI:1184857112
Name:OSORIO, SHANNON M (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:OSORIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:MASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-886-3822
Practice Address - Street 1:618 S FOREST AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5338
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-886-3822
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant