Provider Demographics
NPI:1851370118
Name:REILLY, SHANNON B (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:REILLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:B
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-479-8639
Practice Address - Street 1:5008 BRITTONFIELD PKWY
Practice Address - Street 2:SUITE 700
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9248
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-479-8639
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430268363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02648126Medicaid
NYRA6909Medicare PIN