Provider Demographics
NPI:1972548584
Name:GILLIAM, SHANNON L (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37855 WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:COLTONS POINT
Mailing Address - State:MD
Mailing Address - Zip Code:20626-2102
Mailing Address - Country:US
Mailing Address - Phone:571-215-2155
Mailing Address - Fax:
Practice Address - Street 1:12070 OLD LINE CTR STE 303
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3535
Practice Address - Country:US
Practice Address - Phone:301-893-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003161363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical