Provider Demographics
NPI:1497752679
Name:DELONG, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DELONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CARTMILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 FOWLER GROVE BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5050
Mailing Address - Country:US
Mailing Address - Phone:407-614-0528
Mailing Address - Fax:407-614-0529
Practice Address - Street 1:2000 FOWLER GROVE BLVD FL 3
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5050
Practice Address - Country:US
Practice Address - Phone:407-614-0528
Practice Address - Fax:407-614-0529
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291344500Medicaid
FL291344500Medicaid