Provider Demographics
NPI:1720244957
Name:SHANNON, ALVINA C (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALVINA
Middle Name:C
Last Name:SHANNON
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 1:4228 PARK PLACE CIR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1550
Mailing Address - Country:US
Mailing Address - Phone:404-403-9793
Mailing Address - Fax:
Practice Address - Street 1:4475 W VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2869
Practice Address - Country:US
Practice Address - Phone:770-507-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002735363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical