Provider Demographics
NPI:1952090268
Name:SHANNON, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
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 1:406 CHATHAM SQUARE OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2585
Mailing Address - Country:US
Mailing Address - Phone:540-903-4135
Mailing Address - Fax:
Practice Address - Street 1:406 CHATHAM SQUARE OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-2585
Practice Address - Country:US
Practice Address - Phone:540-666-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009187363AM0700X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical