MEDICARE: SHANNON PHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	P133718	NY

General Provider Information

NPI Number	:	1063368272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON PHAN

Provider Business Mailing Address
First Line	:	8584 MCNAMARA DR
Second Line	:
City	:	CLAY
State	:	NY
Zip	:	13041-8819
Country	:	US
Telephone Number	:	315-414-1252
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000 MEDICAL CENTER DRIVE
Second Line	:	SUITE 504
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066
Country	:	US
Telephone Number	:	315-329-2650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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Directions to “ SHANNON PHAN ” Practice Location

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