Provider Demographics
NPI:1801865845
Name:HOGAN, SHANNON M (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:HOGAN
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 1:13555 W MCDOWELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2624
Mailing Address - Country:US
Mailing Address - Phone:623-881-9238
Mailing Address - Fax:623-512-4253
Practice Address - Street 1:13555 W MCDOWELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2624
Practice Address - Country:US
Practice Address - Phone:623-881-9238
Practice Address - Fax:623-512-4253
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1509363AM0700X
NVPA2251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMH0003652OtherDEA
AZS91868Medicare UPIN