Healthcare Provider Details

I. General information

NPI: 1740568062
Provider Name (Legal Business Name): SHANNON DIEHL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 STATE ROUTE 208 STE 15
MONROE NY
10950-4649
US

IV. Provider business mailing address

2 COATES DR
GOSHEN NY
10924-6758
US

V. Phone/Fax

Practice location:
  • Phone: 845-549-1010
  • Fax: 845-565-5027
Mailing address:
  • Phone: 845-651-1400
  • Fax: 845-651-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014968
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: