Provider Demographics
NPI:1629137674
Name:SHANNON, KAREN LYNN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:LYNN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8028 RITCHIE HWY STE 108
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1020
Mailing Address - Country:US
Mailing Address - Phone:410-768-8600
Mailing Address - Fax:410-768-1676
Practice Address - Street 1:8028 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122
Practice Address - Country:US
Practice Address - Phone:410-768-8600
Practice Address - Fax:410-768-1676
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S89867Medicare UPIN