Provider Demographics
NPI:1417767476
Name:MCDERMOTT, SHANNON MARIE (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MCDERMOTT
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 1:211 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07762-1714
Mailing Address - Country:US
Mailing Address - Phone:908-821-5140
Mailing Address - Fax:
Practice Address - Street 1:211 LORRAINE AVE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-1714
Practice Address - Country:US
Practice Address - Phone:908-821-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant