Healthcare Provider Details

I. General information

NPI: 1770893034
Provider Name (Legal Business Name): SHANNON LYNN AUBREY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON LYNN MOYNIHAN PA

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W GENESEE ST
SYRACUSE NY
13204-2243
US

IV. Provider business mailing address

1050 W GENESEE ST
SYRACUSE NY
13204-2243
US

V. Phone/Fax

Practice location:
  • Phone: 315-641-2385
  • Fax: 315-305-4677
Mailing address:
  • Phone: 315-477-4663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014358
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: