Provider Demographics
NPI:1316720857
Name:O'BRIEN, SHANNON (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14961 W BELL RD STE 175
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-3220
Mailing Address - Country:US
Mailing Address - Phone:623-547-7205
Mailing Address - Fax:623-243-6733
Practice Address - Street 1:14961 W BELL RD STE 175
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3220
Practice Address - Country:US
Practice Address - Phone:623-547-7205
Practice Address - Fax:623-243-6733
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ9820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program