Provider Demographics
NPI:1689045601
Name:SHANNON, PAIGE (PA-C)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:SHANNON
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 1:1024 FOLKESTONE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3706
Mailing Address - Country:US
Mailing Address - Phone:317-697-2561
Mailing Address - Fax:
Practice Address - Street 1:2323 W 5TH AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-4899
Practice Address - Country:US
Practice Address - Phone:614-224-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant