Provider Demographics
NPI:1831931112
Name:MCENERNEY, SHANNON A (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:A
Last Name:MCENERNEY
Suffix:
Gender:
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 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-888-5527
Mailing Address - Fax:203-888-3727
Practice Address - Street 1:220 MAIN ST STE 1A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:CT
Practice Address - Zip Code:06478-1065
Practice Address - Country:US
Practice Address - Phone:203-888-5527
Practice Address - Fax:203-888-3727
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant