Provider Demographics
NPI:1285724245
Name:RICHARDSON, SHANNON L (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4451
Mailing Address - Fax:970-490-4199
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:STE 4007
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-776-8600
Practice Address - Fax:719-634-1448
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2017-12-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
COPA-2330363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA-2330OtherLICENSE