Provider Demographics
NPI:1023519246
Name:BEDNARZ, SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BEDNARZ
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 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-480-2135
Mailing Address - Fax:
Practice Address - Street 1:1370 E VENICE AVE STE 205
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-9084
Practice Address - Country:US
Practice Address - Phone:941-488-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8647OtherGEORGIA PHYSICIAN ASSISTANT MEDICAL LICENSE