Provider Demographics
NPI:1902060387
Name:WHITE, SHANNA U (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:U
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:U
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 HORWOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:ODGENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-394-9462
Mailing Address - Fax:315-713-5291
Practice Address - Street 1:100 HORWOOD PLACE
Practice Address - Street 2:
Practice Address - City:ODGENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669
Practice Address - Country:US
Practice Address - Phone:315-394-9462
Practice Address - Fax:315-713-5291
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015600363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03770858Medicaid