Provider Demographics
NPI:1871803676
Name:CONVERY, SHANNON MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:CONVERY
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 1:4211 WOOSTER RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3417
Mailing Address - Country:US
Mailing Address - Phone:440-289-7243
Mailing Address - Fax:
Practice Address - Street 1:5172 LEAVITT RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-2384
Practice Address - Country:US
Practice Address - Phone:440-282-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03157363AM0700X
TX1052607 NCCPA NUMBER363A00000X
OH50.002241363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant