Provider Demographics
NPI:1891443693
Name:SHANAHAN, KEVIN JUDE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JUDE
Last Name:SHANAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1669
Mailing Address - Country:US
Mailing Address - Phone:708-681-2298
Mailing Address - Fax:
Practice Address - Street 1:8321 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1669
Practice Address - Country:US
Practice Address - Phone:708-681-2298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant