Provider Demographics
NPI:1942482914
Name:WIDDERICK, SHANNON M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:WIDDERICK
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 1:395 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3914
Mailing Address - Country:US
Mailing Address - Phone:413-584-7787
Mailing Address - Fax:413-584-7778
Practice Address - Street 1:395 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3914
Practice Address - Country:US
Practice Address - Phone:413-584-7787
Practice Address - Fax:413-584-7778
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001992363A00000X
MA2360363A00000X
MAPA2360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003019924Medicaid
MA00000000Medicare PIN
CT003019924Medicaid