Provider Demographics
NPI:1215356811
Name:LOFGREN, SHANNON O'DONNELL (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:O'DONNELL
Last Name:LOFGREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3073 HAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2006
Mailing Address - Country:US
Mailing Address - Phone:305-322-6263
Mailing Address - Fax:
Practice Address - Street 1:455 PINELLAS ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3354
Practice Address - Country:US
Practice Address - Phone:305-322-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant