Provider Demographics
NPI:1255883310
Name:LAVIS, SHANNON MARIE (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:LAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WILLETT ST
Mailing Address - Street 2:APT 4
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12210-1183
Mailing Address - Country:US
Mailing Address - Phone:570-591-6416
Mailing Address - Fax:
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:0203 MCAULEY
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant