Provider Demographics
NPI:1639611726
Name:MASSRY, SHANNAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNAN
Middle Name:
Last Name:MASSRY
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 1:2206 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4831
Mailing Address - Country:US
Mailing Address - Phone:646-271-0934
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020362-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant