Provider Demographics
NPI:1639718836
Name:LISA SHANNON DO, PA
Entity Type:Organization
Organization Name:LISA SHANNON DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:941-746-4151
Mailing Address - Street 1:250 2ND ST E STE 3B
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1027
Mailing Address - Country:US
Mailing Address - Phone:941-746-4151
Mailing Address - Fax:
Practice Address - Street 1:250 2ND ST E STE 3B
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1027
Practice Address - Country:US
Practice Address - Phone:941-746-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011944000Medicaid