Provider Demographics
NPI:1053365262
Name:EARLEY, SHANNA M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:M
Last Name:EARLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:MARIE
Other - Last Name:COWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:91 HORNER ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-6306
Mailing Address - Country:US
Mailing Address - Phone:304-224-1216
Mailing Address - Fax:
Practice Address - Street 1:425 W 5TH ST
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2405
Practice Address - Country:US
Practice Address - Phone:330-386-2010
Practice Address - Fax:330-386-2061
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01470363A00000X
OH50.002614RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010081785Medicaid
OH0098446Medicaid
VA010081785Medicaid
003961D82Medicare ID - Type UnspecifiedGRP C08682
OHH065332Medicare PIN