Provider Demographics
NPI:1497966980
Name:WELNER, SHANNON L (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:WELNER
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 1:60 POMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2946
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:973-571-2126
Practice Address - Street 1:60 POMPTON AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2946
Practice Address - Country:US
Practice Address - Phone:973-571-2121
Practice Address - Fax:973-571-2126
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00146000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1962428474OtherGROUP NPI NUMBER
NJ25MP00146000OtherSTATE LICENSE