Provider Demographics
NPI:1467820688
Name:SEVERINO, SHANNON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:SEVERINO
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 1:250 S 21ST ST
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-3851
Mailing Address - Country:US
Mailing Address - Phone:610-250-4001
Mailing Address - Fax:
Practice Address - Street 1:250 S 21ST ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-3851
Practice Address - Country:US
Practice Address - Phone:610-250-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1130197363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical