Provider Demographics
NPI:1194379248
Name:BLANFORD, SHANNON (STUDENT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLANFORD
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HUNT DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1228
Mailing Address - Country:US
Mailing Address - Phone:315-412-1117
Mailing Address - Fax:
Practice Address - Street 1:2209 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5930
Practice Address - Country:US
Practice Address - Phone:315-801-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-27
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024233363A00000X, 363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program