Healthcare Provider Details

I. General information

NPI: 1801865845
Provider Name (Legal Business Name): SHANNON M. HOGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/07/2023
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13555 W MCDOWELL RD SUITE 101
GOODYEAR AZ
85338-2624
US

IV. Provider business mailing address

13555 W MCDOWELL RD SUITE 101
GOODYEAR AZ
85338-2624
US

V. Phone/Fax

Practice location:
  • Phone: 623-881-9238
  • Fax: 623-512-4253
Mailing address:
  • Phone: 623-881-9238
  • Fax: 623-512-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2251
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1509
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: