Provider Demographics
NPI:1871216341
Name:MACKEY, SHANNON ASHLEY (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ASHLEY
Last Name:MACKEY
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 1:530 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4855
Mailing Address - Country:US
Mailing Address - Phone:212-717-8282
Mailing Address - Fax:
Practice Address - Street 1:530 E 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4855
Practice Address - Country:US
Practice Address - Phone:212-717-8282
Practice Address - Fax:212-717-9643
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY15080667052084N0400X
NY029209208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology