Provider Demographics
NPI:1023678620
Name:WATTS, SHANNON LYNN (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LYNN
Last Name:WATTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNN
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1464 ROCKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-1302
Mailing Address - Country:US
Mailing Address - Phone:443-981-9539
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007101363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical