Basic Information
| Provider Information | |||||||||
| NPI: | 1407954357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 MARTHA AVE | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027771617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086757708 | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 BELMONT ST | ||||||||
| Address2: | VA BOSTON HEALTHCARE SYSTEM | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085834500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 894 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.