Provider Demographics
NPI:1558133603
Name:MA, SHANNA
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12427 FEATHER DR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:91752-1484
Mailing Address - Country:US
Mailing Address - Phone:909-272-9283
Mailing Address - Fax:
Practice Address - Street 1:980 E FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4068
Practice Address - Country:US
Practice Address - Phone:909-981-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily