Provider Demographics
NPI:1144249517
Name:SHANAVER, ERIN M (PA)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:M
Last Name:SHANAVER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2746
Mailing Address - Country:US
Mailing Address - Phone:603-421-2143
Mailing Address - Fax:
Practice Address - Street 1:1 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2746
Practice Address - Country:US
Practice Address - Phone:603-421-2143
Practice Address - Fax:603-421-2344
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0532P363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30333268Medicaid
NH000041601Medicare PIN
NH30333268Medicaid