Provider Demographics
NPI:1588133342
Name:DWYER, SHANNON M (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:DWYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6569
Mailing Address - Fax:315-298-7831
Practice Address - Street 1:10 GEORGE ST STE 200
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3276
Practice Address - Country:US
Practice Address - Phone:315-342-0880
Practice Address - Fax:315-593-6195
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343293363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily