Provider Demographics
NPI:1669665303
Name:BRADY-POWERS, SHANNON (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRADY-POWERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 CHESTNUT ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4216
Mailing Address - Country:US
Mailing Address - Phone:215-955-6760
Mailing Address - Fax:215-923-4532
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:SIXTH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-6760
Practice Address - Fax:215-923-4532
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN536907163WX0601X
PASP009125363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WX0601XNursing Service ProvidersRegistered NurseOtorhinolaryngology & Head-Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102879964Medicaid
PA102879964Medicaid