Provider Demographics
NPI:1982118378
Name:REILLY, SHANNON M (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:REILLY
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:PO BOX 643398
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-3398
Mailing Address - Country:US
Mailing Address - Phone:513-221-1100
Mailing Address - Fax:513-684-4501
Practice Address - Street 1:3825 EDWARDS RD STE 300
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1288
Practice Address - Country:US
Practice Address - Phone:513-221-1100
Practice Address - Fax:513-684-4501
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07438363A00000X
OH50.007901RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730004OtherNSC