Provider Demographics
NPI:1457712101
Name:KASPER, SHANNON (DNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KASPER
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4993 TIM TAM TRL
Mailing Address - Street 2:
Mailing Address - City:BLASDELL
Mailing Address - State:NY
Mailing Address - Zip Code:14219-2633
Mailing Address - Country:US
Mailing Address - Phone:716-998-1405
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3011
Practice Address - Country:US
Practice Address - Phone:585-922-4518
Practice Address - Fax:585-336-5113
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307673363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health