Provider Demographics
NPI:1902060387
Name:WHITE, SHANNA U (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:U
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:U
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:34 CORNELL DRVIE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617
Mailing Address - Country:US
Mailing Address - Phone:315-386-3897
Mailing Address - Fax:
Practice Address - Street 1:76 PARK ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1506
Practice Address - Country:US
Practice Address - Phone:315-229-5392
Practice Address - Fax:315-229-5514
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA233363AM0700X
NY015600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical