Provider Demographics
NPI:1902577604
Name:DUFFY, SHANNON (MMSC, PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DUFFY
Suffix:
Gender:F
Credentials:MMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 N DECATUR RD APT 1408
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6179
Mailing Address - Country:US
Mailing Address - Phone:303-704-3534
Mailing Address - Fax:
Practice Address - Street 1:1951 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3415
Practice Address - Country:US
Practice Address - Phone:404-321-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA11447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program