Provider Demographics
NPI:1225367519
Name:SHANNON, MARK JAY (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JAY
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1201 ALHAMBRA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5238
Practice Address - Country:US
Practice Address - Phone:916-733-5090
Practice Address - Fax:916-733-5062
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA12702363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMS1228154OtherDEA #