Provider Demographics
NPI:1881139863
Name:SHANNON, GRANT (NP)
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:MR
Other - First Name:PATRICK
Other - Middle Name:GRANT
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:206 CORNELIA ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2878
Mailing Address - Country:US
Mailing Address - Phone:518-561-5516
Mailing Address - Fax:
Practice Address - Street 1:206 CORNELIA ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2878
Practice Address - Country:US
Practice Address - Phone:518-561-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308051-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health