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NPI Code Detail

MEDICARE: MRS. SHANNON MALLORY FATSEAS PA-C

MEDICARE: MRS. SHANNON MALLORY FATSEAS PA-C
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
1363A00000XPhysician Assistant50.004255RXOH
2363AM0700XMedical Physician Assistant50.004255OH

General Provider Information

NPI Number : 1972834240
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SHANNON MALLORY FATSEAS PA-C
Provider Business Mailing Address
First Line : 3400 OLENTANGY RIVER RD
Second Line :
City : COLUMBUS
State : OH
Zip : 43202-1523
Country : US
Telephone Number : 614-754-5500
Fax Number : 614-754-5500
Provider Business Practice Location Address
First Line : 3400 OLENTANGY RIVER RD
Second Line :
City : COLUMBUS
State : OH
Zip : 43202-1523
Country : US
Telephone Number : 614-754-5500
Fax Number : 614-754-5500
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/26/2010
Last Update Date : 02/20/2026

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Directions to “ MRS. SHANNON MALLORY FATSEAS PA-C” Practice Location

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