Provider Demographics
NPI:1821719899
Name:CISLO, SHANNON MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:CISLO
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Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5001
Practice Address - Street 1:11261 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7230
Practice Address - Country:US
Practice Address - Phone:904-292-9033
Practice Address - Fax:904-292-4127
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2023-08-17
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant