Provider Demographics
NPI:1194987123
Name:FREDERICK, SHANNON NICOLE (PAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PAC
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Mailing Address - Street 1:1456 FERRY RD
Mailing Address - Street 2:STE 402
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-2307
Mailing Address - Country:US
Mailing Address - Phone:215-348-2992
Mailing Address - Fax:215-348-2052
Practice Address - Street 1:14 MEMORIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901
Practice Address - Country:US
Practice Address - Phone:215-348-2992
Practice Address - Fax:215-348-2052
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2018-04-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA003232L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical