Provider Demographics
NPI:1407954357
Name:SHANNON, KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SHANNON
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 1:9 MARTHA AVE
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-1617
Mailing Address - Country:US
Mailing Address - Phone:508-675-7708
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:VA BOSTON HEALTHCARE SYSTEM
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:508-583-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA894363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical