Provider Demographics
NPI:1477011591
Name:MANNO, SHANNON ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:MANNO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26850 PROVIDENCE PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1256
Mailing Address - Country:US
Mailing Address - Phone:248-465-5140
Mailing Address - Fax:248-465-5141
Practice Address - Street 1:26850 PROVIDENCE PKWY STE 260
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1256
Practice Address - Country:US
Practice Address - Phone:248-465-5140
Practice Address - Fax:248-465-5141
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009039207XX0005X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine