Provider Demographics
NPI:1629337902
Name:MOREAU, SHANNON N (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:N
Last Name:MOREAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:N
Other - Last Name:RECORDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-791-3888
Mailing Address - Fax:
Practice Address - Street 1:61 BARRA RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9459
Practice Address - Country:US
Practice Address - Phone:207-283-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0900363AM0700X
MEPA1327363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
T400121175Medicare PIN