Provider Demographics
NPI:1700326824
Name:O'BRIEN, SHANNAN THERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:THERESA
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:THERESA
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2320 FREEWAY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5445
Practice Address - Country:US
Practice Address - Phone:360-814-6880
Practice Address - Fax:360-814-6953
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60740417363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical