MEDICARE: MR. GRANT SHANNON N.P.

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	363LA2200X	Adult Health Nurse Practitioner	F308051-1	NY

General Provider Information

NPI Number	:	1881139863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GRANT SHANNON N.P.

Provider Business Mailing Address
First Line	:	206 CORNELIA ST
Second Line	:	SUITE 105
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2878
Country	:	US
Telephone Number	:	518-561-5516
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 CORNELIA ST
Second Line	:	SUITE 105
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2878
Country	:	US
Telephone Number	:	518-561-5516
Fax Number	:

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

Provider Enumeration Date	:	12/29/2016
Last Update Date	:	05/11/2017

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