MEDICARE: SHANNON CAMPBELL

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	363A00000X	Physician Assistant	25MP00841700	NJ
2	363A00000X	Physician Assistant		NY

General Provider Information

NPI Number	:	1568081248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON CAMPBELL

Provider Business Mailing Address
First Line	:	570 LEXINGTON AVE FL 9
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-6710
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 DAVIS AVE
Second Line	:
City	:	NEPTUNE
State	:	NJ
Zip	:	07753-4488
Country	:	US
Telephone Number	:	732-775-5500
Fax Number	:

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

Provider Enumeration Date	:	04/13/2020
Last Update Date	:	12/10/2025

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Directions to “ SHANNON CAMPBELL ” Practice Location

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