Provider Demographics
NPI:1417911140
Name:BARTLETT, SHANNON JO (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JO
Last Name:BARTLETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 MALSBARY ROAD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5644
Mailing Address - Country:US
Mailing Address - Phone:513-272-0261
Mailing Address - Fax:513-272-0362
Practice Address - Street 1:4380 MALSBARY ROAD
Practice Address - Street 2:SUITE 175
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-5644
Practice Address - Country:US
Practice Address - Phone:513-272-0261
Practice Address - Fax:513-272-0362
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001961363A00000X
OH50.001961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00115908OtherRAILROAD MEDICARE PIN
OHP00115908OtherRAILROAD MEDICARE PIN
OHBAPA22991Medicare PIN
OHBAPA35901Medicare PIN