Provider Demographics
NPI:1639521354
Name:MCCARTHY, SHANNON AILEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:AILEEN
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 MICHIGAN ST NE BLDG 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2578
Mailing Address - Country:US
Mailing Address - Phone:616-459-8209
Mailing Address - Fax:616-459-0131
Practice Address - Street 1:833 MICHIGAN ST NE BLDG 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2578
Practice Address - Country:US
Practice Address - Phone:616-459-8209
Practice Address - Fax:616-459-0131
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5601011545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant