Basic Information
| Provider Information | |||||||||
| NPI: | 1467008987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANABROOK | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176377755 | ||||||||
| FaxNumber: | 7176377142 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176377755 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2019 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA005438 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 103837806 | 05 | PA | MEDICAID |