Basic Information
| Provider Information | |||||||||
| NPI: | 1730791146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8705 CREEKSCAPE LN APT 824 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452492063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402514816 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372984331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2020 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50.006576RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1160649 | 01 | NCCPA | OTHER |