MEDICARE: MS. SHANNON R MAHONEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	085002384	IL
2	363AM0700X	Medical Physician Assistant	PA07353	TX

General Provider Information

NPI Number	:	1093700858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNON R MAHONEY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-645-4673
Fax Number	:	214-645-2615

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-7208
Country	:	US
Telephone Number	:	214-645-4673
Fax Number	:	214-645-2615

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	12/20/2016

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