Provider Demographics
NPI:1396790358
Name:SGRO, SHANNON RAE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:SGRO
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 1:1412 BLUE OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7143
Mailing Address - Country:US
Mailing Address - Phone:916-784-7546
Mailing Address - Fax:916-784-7548
Practice Address - Street 1:1412 BLUE OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7143
Practice Address - Country:US
Practice Address - Phone:916-784-7546
Practice Address - Fax:916-784-7548
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15649363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA156491Medicare UPIN