Provider Demographics
NPI:1972834240
Name:FATSEAS, SHANNON MALLORY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MALLORY
Last Name:FATSEAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-366-3687
Mailing Address - Fax:614-293-6176
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-366-3687
Practice Address - Fax:614-293-6176
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004255RX363A00000X
OH50.004255363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLD 5827OtherSTATE DIETITIAN LICENSE