Provider Demographics
NPI:1124158712
Name:SOPP-REILLY, SHAWNNA (PA-C)
Entity type:Individual
Prefix:
First Name:SHAWNNA
Middle Name:
Last Name:SOPP-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 1:476 E CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2142
Mailing Address - Country:US
Mailing Address - Phone:408-378-1888
Mailing Address - Fax:
Practice Address - Street 1:476 E CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2142
Practice Address - Country:US
Practice Address - Phone:408-378-1888
Practice Address - Fax:408-378-5830
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant