Provider Demographics
NPI:1548300585
Name:MCGRATH, SHANNA M (MPH, PA-C, RD, CDE)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:M
Last Name:MCGRATH
Suffix:
Gender:F
Credentials:MPH, PA-C, RD, CDE
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:M
Other - Last Name:MOEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:1001 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8083
Mailing Address - Country:US
Mailing Address - Phone:907-631-7800
Mailing Address - Fax:
Practice Address - Street 1:1001 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8083
Practice Address - Country:US
Practice Address - Phone:907-631-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK193133V00000X
UT390200000X
AK178095363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK193OtherSTATE OF ALASKA LIC