Healthcare Provider Details

I. General information

NPI: 1073178463
Provider Name (Legal Business Name): SHANNEN RENEHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

1160 1ST ST NE
WASHINGTON DC
20002-4696
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-7259
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031607
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: