Provider Demographics
NPI:1669185070
Name:LOPEZ, SHANNON NICOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:NICOLE
Last Name:LOPEZ
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 1:11350 MCCORMICK RD STE 501
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11350 MCCORMICK RD STE 501
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21031-1002
Practice Address - Country:US
Practice Address - Phone:703-738-4371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty