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General NPI Number Information
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NPI Number | 1871803676
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Entity Type | Individual
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Provider Name | SHANNON MARIE CONVERY PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/14/2010
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Last Update Date | 11/18/2020
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Provider Practice Location Address
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Address Line | 5172 LEAVITT RD
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City | LORAIN
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State | OH
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Zip | 44053-2384
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Country | US
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Telephone | 440-282-3385
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Fax |
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Provider Business Mailing Address
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Address Line | 4211 WOOSTER RD
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City | FAIRVIEW PARK
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State | OH
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Zip | 44126-3417
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Country | US
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Telephone | 440-289-7243
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA03157
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1052607 NCCPA NUMBER
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 50.002241
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License Number State | OH
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