Healthcare Provider Details

I. General information

NPI: 1225367519
Provider Name (Legal Business Name): MARK JAY SHANNON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ALHAMBRA BLVD SUITE 400
SACRAMENTO CA
95816-5238
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-733-5090
  • Fax: 916-733-5062
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA12702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: