Provider Demographics
NPI:1477052470
Name:SHAUGHNESSY, MAGDALENE CLARE (PA-C)
Entity type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:CLARE
Last Name:SHAUGHNESSY
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 1:515 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5929
Mailing Address - Country:US
Mailing Address - Phone:405-473-3810
Mailing Address - Fax:
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55241363A00000X
ORPA185332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55241OtherPHYSICIAN ASSISTANT LICENSE