Provider Demographics
NPI:1174810808
Name:EVELLIS, SHANNON T (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:T
Last Name:EVELLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:T
Other - Last Name:EVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:
Practice Address - Street 1:161 CAREY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-7821
Practice Address - Country:US
Practice Address - Phone:518-824-8610
Practice Address - Fax:518-824-2390
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03415487Medicaid
NY03415487Medicaid