Provider Demographics
NPI:1326276379
Name:CORCORAN, SHANNON KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 EASTWIND DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3376
Mailing Address - Country:US
Mailing Address - Phone:614-268-9561
Mailing Address - Fax:614-268-7849
Practice Address - Street 1:955 EASTWIND DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-3376
Practice Address - Country:US
Practice Address - Phone:888-444-1203
Practice Address - Fax:614-268-7849
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50.003075363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00900285OtherRR MEDICARE
PA35831Medicare PIN