Provider Demographics
NPI:1740568062
Name:DIEHL, SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DIEHL
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 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:1200 STATE ROUTE 208 STE 15
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4649
Practice Address - Country:US
Practice Address - Phone:845-549-1010
Practice Address - Fax:845-565-5027
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014968OtherLICENSE