Provider Demographics
NPI:1700209418
Name:TREGO, SHANNON LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:TREGO
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 1:8739 ROCK LODGE RD
Mailing Address - Street 2:
Mailing Address - City:ACCIDENT
Mailing Address - State:MD
Mailing Address - Zip Code:21520-1126
Mailing Address - Country:US
Mailing Address - Phone:410-726-1443
Mailing Address - Fax:301-334-1819
Practice Address - Street 1:8739 ROCK LODGE RD
Practice Address - Street 2:
Practice Address - City:ACCIDENT
Practice Address - State:MD
Practice Address - Zip Code:21520-1126
Practice Address - Country:US
Practice Address - Phone:410-726-1443
Practice Address - Fax:301-334-1819
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant