Healthcare Provider Details

I. General information

NPI: 1942482914
Provider Name (Legal Business Name): SHANNON M. WIDDERICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 PLEASANT ST
NORTHAMPTON MA
01060-3914
US

IV. Provider business mailing address

395 PLEASANT ST
NORTHAMPTON MA
01060-3914
US

V. Phone/Fax

Practice location:
  • Phone: 413-584-7787
  • Fax: 413-584-7778
Mailing address:
  • Phone: 413-584-7787
  • Fax: 413-584-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001992
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2360
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2360
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: