Healthcare Provider Details

I. General information

NPI: 1467820688
Provider Name (Legal Business Name): SHANNON SEVERINO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

IV. Provider business mailing address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 484-658-2366
  • Fax: 833-329-4059
Mailing address:
  • Phone: 484-658-2366
  • Fax: 833-329-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00679300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA057820
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: