Provider Demographics
NPI:1376067496
Name:SHAH, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4028
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:225 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1523
Practice Address - Country:US
Practice Address - Phone:212-639-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308256363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health