Healthcare Provider Details

I. General information

NPI: 1598092199
Provider Name (Legal Business Name): SHANNON N. FULMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON N. MEADE PA-C

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-1339
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6259
  • Fax:
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054146
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: