Basic Information
Provider Information | |||||||||
NPI: | 1659962207 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOHOLLEN | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRADLEY | ||||||||
OtherFirstName: | SHANNON | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 223 WILMINGTON W CHESTER PIKE STE 214 | ||||||||
Address2: |   | ||||||||
City: | CHADDS FORD | ||||||||
State: | PA | ||||||||
PostalCode: | 193179007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8443657246 | ||||||||
FaxNumber: | 8445160080 | ||||||||
Practice Location | |||||||||
Address1: | 405 SILVERSIDE RD STE 104 | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 198091768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8443657246 | ||||||||
FaxNumber: | 8445160080 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2021 | ||||||||
LastUpdateDate: | 10/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA062225 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | C5-0011500 | DE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.