Provider Demographics
NPI:1487809083
Name:MOONEY, SHANNON M (PAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:MOONEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:WESCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 LODER ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1112
Mailing Address - Country:US
Mailing Address - Phone:585-596-4088
Mailing Address - Fax:
Practice Address - Street 1:13 LODER ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895
Practice Address - Country:US
Practice Address - Phone:585-596-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13006363A00000X
NY013006-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant