Provider Demographics
NPI:1194883066
Name:DIPAOLA, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:DIPAOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SHINNECOCK LN
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 SHINNECOCK LN
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-3124
Practice Address - Country:US
Practice Address - Phone:516-663-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant