Provider Demographics
NPI:1639403892
Name:GANNON, SHANNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:M
Last Name:GANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:NICOLE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2200 WHITNEY AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3694
Mailing Address - Country:US
Mailing Address - Phone:203-281-7000
Mailing Address - Fax:
Practice Address - Street 1:2200 WHITNEY AVE STE 270
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3694
Practice Address - Country:US
Practice Address - Phone:203-281-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2318363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003023181Medicaid
CTD400039337 - C00023Medicare PIN
CTD400039334 - C00814Medicare PIN