Basic Information
| Provider Information | |||||||||
| NPI: | 1407004898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROSE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | RPA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARKER | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1555 LONG POND RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237281 | ||||||||
| FaxNumber: | 5857238660 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 RED CREEK DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146234262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237600 | ||||||||
| FaxNumber: | 5853346373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2008 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 012694 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 03607632 | 05 | NY | MEDICAID |