Provider Demographics
NPI:1407676562
Name:WENTER, SHANNON NICOLE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:WENTER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4602 SAGEMORE DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3939
Mailing Address - Country:US
Mailing Address - Phone:609-744-6562
Mailing Address - Fax:
Practice Address - Street 1:132 GROVE ST
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1224
Practice Address - Country:US
Practice Address - Phone:856-354-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00885700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant