Provider Demographics
NPI:1922178045
Name:JOHNSON, SHANNON ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:JOHNSON
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 1:4 FERNDALE LN
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-9418
Mailing Address - Country:US
Mailing Address - Phone:607-749-6511
Mailing Address - Fax:607-844-4922
Practice Address - Street 1:83 LEWIS ST
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053
Practice Address - Country:US
Practice Address - Phone:607-844-8201
Practice Address - Fax:607-844-4922
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007939-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8015Medicare ID - Type Unspecified
NYP39318Medicare UPIN