Provider Demographics
NPI:1659962207
Name:MOHOLLEN, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MOHOLLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:291 CARTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-5845
Mailing Address - Country:US
Mailing Address - Phone:844-365-7246
Mailing Address - Fax:844-516-0080
Practice Address - Street 1:405 SILVERSIDE RD STE 104
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-1768
Practice Address - Country:US
Practice Address - Phone:844-365-7246
Practice Address - Fax:844-516-0080
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062225363A00000X
DEC5-0011500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant