Healthcare Provider Details

I. General information

NPI: 1235848268
Provider Name (Legal Business Name): SHANNON LY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3413 W PACIFIC AVE STE 102
BURBANK CA
91505-1598
US

IV. Provider business mailing address

PO BOX 505
TEMPLE CITY CA
91780-0505
US

V. Phone/Fax

Practice location:
  • Phone: 818-953-4408
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: