Provider Demographics
NPI:1356779086
Name:PERRY, SHAWNA (PA-C)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:PERRY
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 1:334 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DICKSON CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18519-1668
Mailing Address - Country:US
Mailing Address - Phone:570-307-1767
Mailing Address - Fax:570-307-1778
Practice Address - Street 1:334 MAIN ST
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1668
Practice Address - Country:US
Practice Address - Phone:570-307-1767
Practice Address - Fax:570-307-1778
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056542363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA056542OtherPA LICENSE
1113405OtherNCCPA NUMBER