Provider Demographics
NPI:1740568062
Name:DIEHL, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DIEHL
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 1:1065 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-2417
Mailing Address - Country:US
Mailing Address - Phone:718-589-2440
Mailing Address - Fax:
Practice Address - Street 1:6 HENRY ST
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-3058
Practice Address - Country:US
Practice Address - Phone:845-831-0400
Practice Address - Fax:845-765-9400
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014968OtherLICENSE