Provider Demographics
NPI:1518233378
Name:ADAMS, SHANNON M (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:ADAMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:14540 OLD ST. AUGUSTINE ROAD
Practice Address - Street 2:SUITE 2391
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7418
Practice Address - Country:US
Practice Address - Phone:904-262-3372
Practice Address - Fax:904-262-3306
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106497OtherLICENSE
FLFY508YMedicare PIN