Provider Demographics
NPI:1407004898
Name:DEROSE, SHANNON (RPA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DEROSE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1555 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7281
Mailing Address - Fax:585-723-8660
Practice Address - Street 1:125 RED CREEK DR STE 205
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-4262
Practice Address - Country:US
Practice Address - Phone:585-723-7600
Practice Address - Fax:585-334-6373
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012694363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03607632Medicaid
NY03607632Medicaid
NYJ400080454/GRPBA0017Medicare PIN