Provider Demographics
NPI:1861177370
Name:LAW-CLARK, SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LAW-CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54A HERCULES RD
Mailing Address - Street 2:
Mailing Address - City:KENVIL
Mailing Address - State:NJ
Mailing Address - Zip Code:07847-2674
Mailing Address - Country:US
Mailing Address - Phone:973-699-7861
Mailing Address - Fax:
Practice Address - Street 1:1 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3771
Practice Address - Country:US
Practice Address - Phone:973-302-6025
Practice Address - Fax:862-357-8424
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00788200363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant