Provider Demographics
NPI:1962389593
Name:SHANNON, MARTINA ANDREA (PA-C)
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:ANDREA
Last Name:SHANNON
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 1:966 12TH ST SE STE 130
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2860
Mailing Address - Country:US
Mailing Address - Phone:503-837-6395
Mailing Address - Fax:
Practice Address - Street 1:966 12TH ST SE STE 130
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2860
Practice Address - Country:US
Practice Address - Phone:503-837-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant