Provider Demographics
NPI:1568770675
Name:SHANNON, JANINE (RPA-C)
Entity Type:Individual
Prefix:MISS
First Name:JANINE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9711 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7702
Mailing Address - Country:US
Mailing Address - Phone:718-833-1808
Mailing Address - Fax:718-836-3711
Practice Address - Street 1:9711 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7702
Practice Address - Country:US
Practice Address - Phone:718-833-1808
Practice Address - Fax:718-836-3711
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014373363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA4000039440Medicare PIN